Provider Demographics
NPI:1033826136
Name:RUSSELL, ALLEN FLOYD
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:FLOYD
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 1:2529 BRIDGEPORT LN SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-8431
Mailing Address - Country:US
Mailing Address - Phone:616-340-9026
Mailing Address - Fax:
Practice Address - Street 1:4488 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5270
Practice Address - Country:US
Practice Address - Phone:616-340-9026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No174200000XOther Service ProvidersMeals
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)