Provider Demographics
NPI:1982331823
Name:RUSSELL, LAURA GRACE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GRACE
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 1:5554 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2200
Mailing Address - Country:US
Mailing Address - Phone:818-705-5522
Mailing Address - Fax:
Practice Address - Street 1:5554 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2200
Practice Address - Country:US
Practice Address - Phone:818-705-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician