Provider Demographics
NPI:1326204132
Name:RUSSELL, REBECCA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SCOTT DR
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-9796
Mailing Address - Country:US
Mailing Address - Phone:870-251-2341
Mailing Address - Fax:870-251-3316
Practice Address - Street 1:70 SCOTT DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-9796
Practice Address - Country:US
Practice Address - Phone:870-251-2341
Practice Address - Fax:870-251-3316
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1435235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136394721Medicaid