Provider Demographics
NPI:1801235957
Name:BELLAMY, RUSSELL STEVEN (LAC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:STEVEN
Last Name:BELLAMY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:RUSS
Other - Middle Name:
Other - Last Name:BELLAMY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2809 FOREST HOME RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5320
Mailing Address - Country:US
Mailing Address - Phone:866-972-1268
Mailing Address - Fax:
Practice Address - Street 1:3358 S 2ND ST STE A-C
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7873
Practice Address - Country:US
Practice Address - Phone:501-286-6053
Practice Address - Fax:501-286-6090
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1706220101YM0800X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR259512795Medicaid