Provider Demographics
NPI:1558913012
Name:RUSSELL, BEVERLY JEAN
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JEAN
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 1:120 E MARKET ST STE 1233
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3250
Mailing Address - Country:US
Mailing Address - Phone:317-455-5307
Mailing Address - Fax:
Practice Address - Street 1:120 E MARKET ST STE 1233
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-3250
Practice Address - Country:US
Practice Address - Phone:317-455-5307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician