Provider Demographics
NPI:1790115483
Name:RUSSELL, SARAH MICHELE (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MICHELE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS, 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 724
Mailing Address - Street 2:3695 KIDS LANE
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-0724
Mailing Address - Country:US
Mailing Address - Phone:843-450-0295
Mailing Address - Fax:
Practice Address - Street 1:3695 KIDS LN
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-4901
Practice Address - Country:US
Practice Address - Phone:843-450-0295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1-13-14374103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst