Provider Demographics
NPI:1124505235
Name:RUSSELL, SADIE (BCBA)
Entity type:Individual
Prefix:
First Name:SADIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S MOPAC EXPY
Mailing Address - Street 2:STE C-300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22001 NORTHPARK DR STE 400
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3809
Practice Address - Country:US
Practice Address - Phone:281-222-3530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-21
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-20-42917103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst