Provider Demographics
NPI: | 1013059526 |
---|---|
Name: | RUSSELL, ANDREA A (PHD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ANDREA |
Middle Name: | A |
Last Name: | RUSSELL |
Suffix: | |
Gender: | F |
Credentials: | PHD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 7660 E BROADWAY BLVD |
Mailing Address - Street 2: | SUITE 207 |
Mailing Address - City: | TUCSON |
Mailing Address - State: | AZ |
Mailing Address - Zip Code: | 85710-3774 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 520-885-0557 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 7660 E BROADWAY BLVD |
Practice Address - Street 2: | SUITE 207 |
Practice Address - City: | TUCSON |
Practice Address - State: | AZ |
Practice Address - Zip Code: | 85710-3774 |
Practice Address - Country: | US |
Practice Address - Phone: | 520-885-0557 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2007-02-12 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | AZ LPC 1342 | 103TA0700X, 103TB0200X, 103TC0700X, 103TC1900X, 103TC2200X, 103TF0000X, 103TM1800X, 103T00000X, 103TP2701X, 246ZE0500X, 2472E0500X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 103TA0700X | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging |
Not Answered | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
Not Answered | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical |
Not Answered | 103TC1900X | Behavioral Health & Social Service Providers | Psychologist | Counseling |
Not Answered | 103TC2200X | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
Not Answered | 103TF0000X | Behavioral Health & Social Service Providers | Psychologist | Family |
Not Answered | 103TM1800X | Behavioral Health & Social Service Providers | Psychologist | Intellectual & Developmental Disabilities |
Not Answered | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | |
Not Answered | 103TP2701X | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
Not Answered | 246ZE0500X | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | EEG |
Not Answered | 2472E0500X | Technologists, Technicians & Other Technical Service Providers | Technician, Other | EEG |