MEDICARE: STEPHANIE 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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1376926493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE RUSSELL

Provider Business Mailing Address
First Line	:	801 E CAMELBACK RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-3660
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21505 N 78TH AVE
Second Line	:	125
City	:	PEORIA
State	:	AZ
Zip	:	85382-3356
Country	:	US
Telephone Number	:	603-535-8341
Fax Number	:

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

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/07/2015

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Directions to “ STEPHANIE RUSSELL ” Practice Location

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