Provider Demographics
NPI:1306336847
Name:RUSSELL, CHARLES R (RBT-17-35016)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:RBT-17-35016
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 S HURON ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80110-5636
Mailing Address - Country:US
Mailing Address - Phone:720-435-0048
Mailing Address - Fax:
Practice Address - Street 1:4520 S HURON ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80110-5636
Practice Address - Country:US
Practice Address - Phone:720-435-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-17-35016106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician