Provider Demographics
NPI:1649429465
Name:RUSSELL, TARA NICOLE (MS, BCBA, LBA)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:NICOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:6550 E BROADWAY RD STE 110
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1734
Practice Address - Country:US
Practice Address - Phone:480-672-0772
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
AZBEH-000896103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-48060OtherBCBA CERTIFICATE