Provider Demographics
NPI:1740985746
Name:RUSSELL, EMMA LEIGH
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:LEIGH
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 1:6323 GREAT OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:ALMONT
Mailing Address - State:MI
Mailing Address - Zip Code:48003-9716
Mailing Address - Country:US
Mailing Address - Phone:810-706-0653
Mailing Address - Fax:
Practice Address - Street 1:30330 HICKEY RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051-3911
Practice Address - Country:US
Practice Address - Phone:586-421-4062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician