Provider Demographics
NPI:1003145152
Name:RUSSELL, JULIE (PMHCNS-BC)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 CARLISLE DR STE A
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5623
Mailing Address - Country:US
Mailing Address - Phone:703-581-5875
Mailing Address - Fax:
Practice Address - Street 1:5597 CEDAR BREAK DR
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-3329
Practice Address - Country:US
Practice Address - Phone:703-830-6315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0015000440364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult