Provider Demographics
NPI:1427399336
Name:RUSSELL, AUDREY M (BCBA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:DENHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:1824 TOUBY PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-2573
Mailing Address - Country:US
Mailing Address - Phone:765-628-7400
Mailing Address - Fax:855-940-0177
Practice Address - Street 1:3435 W 96TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1102
Practice Address - Country:US
Practice Address - Phone:317-802-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst