Provider Demographics
NPI:1336781756
Name:RUSSELL, ANDRE
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
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 1343
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11582-1343
Mailing Address - Country:US
Mailing Address - Phone:516-557-5578
Mailing Address - Fax:
Practice Address - Street 1:7 WALLACE CT APT 1
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5557
Practice Address - Country:US
Practice Address - Phone:516-557-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty