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NPI Code Detail

MEDICARE: AUDREY M RUSSELL BCBA

MEDICARE: AUDREY M RUSSELL BCBA
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
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1427399336
Entity Type Code : Individual
Provider Name (Legal Business Name) : AUDREY M RUSSELL BCBA
Provider Business Mailing Address
First Line : 1824 TOUBY PIKE STE B
Second Line :
City : KOKOMO
State : IN
Zip : 46901-2573
Country : US
Telephone Number : 765-628-7400
Fax Number : 855-940-0177
Provider Business Practice Location Address
First Line : 3435 W 96TH ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46268-1102
Country : US
Telephone Number : 317-802-7447
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/04/2013
Last Update Date : 03/09/2022

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