MEDICARE: BRENDA SUE RUSSELL LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	152009	CA

General Provider Information

NPI Number	:	1225289176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA SUE RUSSELL LMFT

Provider Business Mailing Address
First Line	:	1912 LA TIJERA CT
Second Line	:
City	:	OCEANO
State	:	CA
Zip	:	93445-8953
Country	:	US
Telephone Number	:	805-441-3882
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 21ST ST STE 205
Second Line	:
City	:	PASO ROBLES
State	:	CA
Zip	:	93446-1722
Country	:	US
Telephone Number	:	805-441-3882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2008
Last Update Date	:	01/01/2025

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