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NPI Code Detail

MEDICARE: MATTHEW RUSSEY

MEDICARE: MATTHEW RUSSEY
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
1106S00000XBehavior TechnicianRBT-21-173448FL

General Provider Information

NPI Number : 1639843832
Entity Type Code : Individual
Provider Name (Legal Business Name) : MATTHEW RUSSEY
Provider Business Mailing Address
First Line : 1737 N CLYDE MORRIS BLVD
Second Line :
City : DAYTONA BEACH
State : FL
Zip : 32117-5533
Country : US
Telephone Number : 321-888-3020
Fax Number :
Provider Business Practice Location Address
First Line : 1737 N CLYDE MORRIS BLVD
Second Line :
City : DAYTONA BEACH
State : FL
Zip : 32117-5533
Country : US
Telephone Number : 321-888-3020
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/03/2021
Last Update Date : 08/03/2021

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Directions to “ MATTHEW RUSSEY ” Practice Location

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