Provider Demographics
NPI:1013084797
Name:RUSS, THEEANY TF (BA)
Entity Type:Individual
Prefix:
First Name:THEEANY
Middle Name:TF
Last Name:RUSS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1717
Mailing Address - Country:US
Mailing Address - Phone:732-747-9660
Mailing Address - Fax:732-224-1396
Practice Address - Street 1:145 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1717
Practice Address - Country:US
Practice Address - Phone:732-747-9660
Practice Address - Fax:732-224-1396
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator