Provider Demographics
NPI:1427487008
Name:RUSSELL, SANDRA R
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:R
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 1:8920 HOLLY AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2988
Mailing Address - Country:US
Mailing Address - Phone:505-856-6880
Mailing Address - Fax:800-714-4705
Practice Address - Street 1:8920 HOLLY AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2988
Practice Address - Country:US
Practice Address - Phone:505-856-6880
Practice Address - Fax:800-714-4705
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist