MEDICARE: CORNERSTONE CHRISTIAN COUNSELING

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	103TA0700X	Adult Development & Aging Psychologist	AZ LPC 1342	AZ
2	103TB0200X	Cognitive & Behavioral Psychologist	AZ LPC 1342	AZ
3	103TC1900X	Counseling Psychologist	AZ LPC 1342	AZ
4	103TC2200X	Clinical Child & Adolescent Psychologist	AZ LPC 1342	AZ
5	103TF0000X	Family Psychologist	AZ LPC 1342	AZ
6	103TM1800X	Intellectual & Developmental Disabilities Psychologist	AZ LPC 1342	AZ
7	103T00000X	Psychologist	AZ LPC 1342	AZ
8	103TP2701X	Group Psychotherapy Psychologist	AZ LPC 1342	AZ
9	246ZE0500X	EEG Specialist/Technologist	AZ LPC 1342	AZ
10	2472E0500X	EEG Technician	AZ LPC 1342	AZ
11	103TC0700X	Clinical Psychologist	AZ LPC 1342	AZ

General Provider Information

NPI Number	:	1952443467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE CHRISTIAN COUNSELING

Provider Business Mailing Address
First Line	:	7660 E BROADWAY BLVD
Second Line	:	SUITE 207
City	:	TUCSON
State	:	AZ
Zip	:	85710-3774
Country	:	US
Telephone Number	:	520-885-0557
Fax Number	:	520-885-1157

Provider Business Practice Location Address
First Line	:	7660 E BROADWAY BLVD
Second Line	:	SUITE 207
City	:	TUCSON
State	:	AZ
Zip	:	85710-3774
Country	:	US
Telephone Number	:	520-885-0557
Fax Number	:	520-885-1157

Authorized Official
Title or Position	:	LICENSED PSYCHOTHERAPIST
Name	:	DR. ANDREA A. RUSSELL
Credential	:	PH.D.
Telephone Number	:	520-885-0557

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	10/03/2012

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Practice Location Address:

7660 E BROADWAY BLVD , SUITE 207
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