Provider Demographics
NPI:1972933844
Name:BERNALLY-RUSSELL, TISA (BSW, LSAA)
Entity Type:Individual
Prefix:MRS
First Name:TISA
Middle Name:
Last Name:BERNALLY-RUSSELL
Suffix:
Gender:F
Credentials:BSW, LSAA
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 3239
Mailing Address - Street 2:101 W. BROADWAY, SUITE D
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-3239
Mailing Address - Country:US
Mailing Address - Phone:505-327-4796
Mailing Address - Fax:
Practice Address - Street 1:101 W BROADWAY
Practice Address - Street 2:SUITE D
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6419
Practice Address - Country:US
Practice Address - Phone:505-327-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0160331101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)