Provider Demographics
NPI:1255465530
Name:RUSSELL, THERESA JOANNE (CADC-11)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:JOANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CADC-11
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2173 DANBURY WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-2271
Mailing Address - Country:US
Mailing Address - Phone:916-635-6791
Mailing Address - Fax:
Practice Address - Street 1:5494 PONY EXPRESS TRAIL
Practice Address - Street 2:
Practice Address - City:POLLOCK PINES
Practice Address - State:CA
Practice Address - Zip Code:95726
Practice Address - Country:US
Practice Address - Phone:530-664-3758
Practice Address - Fax:530-644-3782
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8463203174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA8463203OtherCADC-11