Provider Demographics
NPI:1053804898
Name:RUSSELL, RACHAEL S
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:S
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 1:46-415 KAHUHIPA ST APT D
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3520
Mailing Address - Country:US
Mailing Address - Phone:270-350-0907
Mailing Address - Fax:
Practice Address - Street 1:41-611 INOAOLE ST
Practice Address - Street 2:
Practice Address - City:WAIMANALO
Practice Address - State:HI
Practice Address - Zip Code:96795-1211
Practice Address - Country:US
Practice Address - Phone:808-892-4059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-16-22167106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician