Provider Demographics
NPI:1649574096
Name:RUSSELL, SHARON ALENE
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:ALENE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:SHARON
Other - Middle Name:ALENE
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:871 CORONADO CENTER DR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-3977
Mailing Address - Country:US
Mailing Address - Phone:702-940-2371
Mailing Address - Fax:702-940-2372
Practice Address - Street 1:871 CORONADO CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-3977
Practice Address - Country:US
Practice Address - Phone:702-940-2371
Practice Address - Fax:702-940-2372
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCP0161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1649574096Medicaid