Provider Demographics
NPI:1619467560
Name:RUSSELL, RONKISHA L (RBT)
Entity Type:Individual
Prefix:MRS
First Name:RONKISHA
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9905 FALLCREEK RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235
Mailing Address - Country:US
Mailing Address - Phone:317-813-4690
Mailing Address - Fax:
Practice Address - Street 1:9905 FALLCREEK RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235
Practice Address - Country:US
Practice Address - Phone:317-813-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-18-48717106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician