Provider Demographics
NPI:1013362060
Name:RUSSELL, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
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 1:8461 EAGLE PRESERVE WAY
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34241-9449
Mailing Address - Country:US
Mailing Address - Phone:941-356-8340
Mailing Address - Fax:
Practice Address - Street 1:405 COMMERCIAL CT STE E
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-1653
Practice Address - Country:US
Practice Address - Phone:941-375-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH11747101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health