Provider Demographics
NPI:1467693432
Name:RUSSELL, DEDRA JANENE (RAS)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:JANENE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38369
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-0369
Mailing Address - Country:US
Mailing Address - Phone:916-929-1951
Mailing Address - Fax:916-929-5116
Practice Address - Street 1:1001 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-3512
Practice Address - Country:US
Practice Address - Phone:916-929-1951
Practice Address - Fax:916-929-5116
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340018AN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility