Provider Demographics
NPI:1225774359
Name:RUSSELL, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
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 1:58 MARBLE RD
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:MA
Mailing Address - Zip Code:01590-2522
Mailing Address - Country:US
Mailing Address - Phone:508-873-8610
Mailing Address - Fax:
Practice Address - Street 1:333 TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1755
Practice Address - Country:US
Practice Address - Phone:888-329-4535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-20-41023OtherBACB CERTIFICATION