MEDICARE: KEEYATTA RUSSELL

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	106S00000X	Behavior Technician		TX

General Provider Information

NPI Number	:	1225973548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEEYATTA RUSSELL

Provider Business Mailing Address
First Line	:	6314 MOUNTAIN PINES LN
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-1905
Country	:	US
Telephone Number	:	336-483-5991
Fax Number	:

Provider Business Practice Location Address
First Line	:	6314 MOUNTAIN PINES LN
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-1905
Country	:	US
Telephone Number	:	336-483-5991
Fax Number	:

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

Provider Enumeration Date	:	04/22/2026
Last Update Date	:	04/22/2026

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Directions to “ KEEYATTA RUSSELL ” Practice Location

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