Provider Demographics
NPI:1710345079
Name:RUSSELL, ERIN MARIE CARROLL (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:ERIN MARIE
Middle Name:CARROLL
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 75
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05669-0075
Mailing Address - Country:US
Mailing Address - Phone:802-595-2957
Mailing Address - Fax:
Practice Address - Street 1:288 GALLISON HILL RD
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:VT
Practice Address - Zip Code:05602-8352
Practice Address - Country:US
Practice Address - Phone:802-793-8307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1062774103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst