Provider Demographics
NPI:1225022148
Name:PEARSON, RUSSELL VERNON (MSW)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:VERNON
Last Name:PEARSON
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3717 E SHAPINSAY DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85242-5038
Mailing Address - Country:US
Mailing Address - Phone:480-987-9460
Mailing Address - Fax:
Practice Address - Street 1:288 N IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-3830
Practice Address - Country:US
Practice Address - Phone:480-982-2356
Practice Address - Fax:480-982-2449
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-41551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ29116Medicare ID - Type Unspecified