Provider Demographics
NPI:1619066156
Name:RUSSELL, JOHN GROVER (NCSP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GROVER
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8188 W BARTLETT RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-7336
Mailing Address - Country:US
Mailing Address - Phone:520-431-4314
Mailing Address - Fax:
Practice Address - Street 1:8188 W BARTLETT RD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-7336
Practice Address - Country:US
Practice Address - Phone:520-431-4314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ584559Medicaid