Provider Demographics
NPI:1932649886
Name:RUSSELL, KERRIE
Entity Type:Individual
Prefix:
First Name:KERRIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14732 OLD SPIKES RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32409-4637
Mailing Address - Country:US
Mailing Address - Phone:850-867-2009
Mailing Address - Fax:
Practice Address - Street 1:14732 OLD SPIKES RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32409-4637
Practice Address - Country:US
Practice Address - Phone:850-867-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-26
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106E00000X106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017422400Medicaid