Provider Demographics
NPI:1437665254
Name:RUSSELL, SHONETTA
Entity Type:Individual
Prefix:
First Name:SHONETTA
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 1:34148 S QUAY RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-4200
Mailing Address - Country:US
Mailing Address - Phone:757-653-4892
Mailing Address - Fax:
Practice Address - Street 1:4016 RAINTREE RD STE 200A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3757
Practice Address - Country:US
Practice Address - Phone:757-465-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty