MEDICARE: RUSSELL APPLETON

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	BH7438	AZ
2	101YP2500X	Professional Counselor	BH7438	AZ
3	1041C0700X	Clinical Social Worker	BH7438	AZ
4	261QM0850X	Adult Mental Health Clinic/Center	BH7438
5	323P00000X	Psychiatric Residential Treatment Facility	BH7438	AZ
6	320800000X	Mental Illness Community Based Residential Treatment Facility	BH7438	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BH7438	OTHER	AZ	DHS - LICENSE FOR BHRF

General Provider Information

NPI Number	:	1386380996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL APPLETON

Provider Business Mailing Address
First Line	:	4726 E WHITE ASTER ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-4908
Country	:	US
Telephone Number	:	602-618-3756
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 N OLIVE AVE
Second Line	:
City	:	CASA GRANDE
State	:	AZ
Zip	:	85122-3418
Country	:	US
Telephone Number	:	602-618-3756
Fax Number	:

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

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	06/19/2024

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Directions to “ RUSSELL APPLETON ” Practice Location

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