Provider Demographics
NPI:1376063149
Name:RUSSELL, ADRIAN ANITA (LASAC)
Entity Type:Individual
Prefix:MS
First Name:ADRIAN
Middle Name:ANITA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6615 NORTH 17TH AVE APT B2
Mailing Address - Street 2:6615 NORTH 17TH AVE APT B2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015
Mailing Address - Country:US
Mailing Address - Phone:480-751-0488
Mailing Address - Fax:602-234-2639
Practice Address - Street 1:2400 N CENTRAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1300
Practice Address - Country:US
Practice Address - Phone:602-264-9891
Practice Address - Fax:602-234-2639
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13352101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)