Basic Information
| Provider Information | |||||||||
| NPI: | 1184677304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7068 N SUNRISE VIS | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863143416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287725477 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 N US HIGHWAY 89 | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863135001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284454860 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LW00007686 | WA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.