Provider Demographics
NPI:1013213438
Name:RUSSELL, TABBY JEANE
Entity Type:Individual
Prefix:
First Name:TABBY
Middle Name:JEANE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 SILVER SAGE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WY
Mailing Address - Zip Code:82636-9532
Mailing Address - Country:US
Mailing Address - Phone:307-251-2459
Mailing Address - Fax:
Practice Address - Street 1:808 SILVER SAGE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WY
Practice Address - Zip Code:82636-9532
Practice Address - Country:US
Practice Address - Phone:307-251-2459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services