1750864849 NPI number — ALEXANDRA L RUSSELL BA, QMHA

Table of content: ALEXANDRA L RUSSELL BA, QMHA (NPI 1750864849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750864849 NPI number — ALEXANDRA L RUSSELL BA, QMHA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
ALEXANDRA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BA, QMHA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUSSELL
Provider Other First Name:
XAN
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
QMHA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1750864849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2073 OLYMPIC ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97477-3413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-682-3550
Provider Business Mailing Address Fax Number:
541-682-3551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2411 MLK JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-682-3550
Provider Business Practice Location Address Fax Number:
541-682-9861
Provider Enumeration Date:
09/13/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)