Basic Information
| Provider Information | |||||||||
| NPI: | 1881076396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REED | ||||||||
| FirstName: | RUSSELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956190699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309570403 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4250 FOWLER LN STE 204 | ||||||||
| Address2: | |||||||||
| City: | DIAMOND SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956199782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306263105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2015 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 100786 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.