Provider Demographics
NPI:1568197077
Name:RUSSELL, BLAKE JEFFREY
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:JEFFREY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3784 MISSION AVE STE 148-1085
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-1460
Mailing Address - Country:US
Mailing Address - Phone:540-383-7133
Mailing Address - Fax:
Practice Address - Street 1:3784 MISSION AVE STE 148-1085
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1460
Practice Address - Country:US
Practice Address - Phone:540-383-7133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician