Provider Demographics
NPI:1649452178
Name:RUSSELL, FREDREAKA
Entity type:Individual
Prefix:
First Name:FREDREAKA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 E HUNT HWY
Mailing Address - Street 2:SUITE 103-230
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85243-6581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 E HUNT HWY
Practice Address - Street 2:SUITE 103-230
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85243-6581
Practice Address - Country:US
Practice Address - Phone:602-579-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker