Provider Demographics
NPI:1437026358
Name:RUSSELL, TIFFANY T
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:T
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 1:6245 DRY FORK RD
Mailing Address - Street 2:
Mailing Address - City:DRY FORK
Mailing Address - State:VA
Mailing Address - Zip Code:24549-4139
Mailing Address - Country:US
Mailing Address - Phone:434-710-0831
Mailing Address - Fax:
Practice Address - Street 1:6245 DRY FORK RD
Practice Address - Street 2:
Practice Address - City:DRY FORK
Practice Address - State:VA
Practice Address - Zip Code:24549-4139
Practice Address - Country:US
Practice Address - Phone:434-710-0831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-23
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11862320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities