Provider Demographics
NPI:1033168927
Name:RUSSELL, SARA ANNE (LPC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9156 E AVENIDA LAS NOCHES
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85218-4675
Mailing Address - Country:US
Mailing Address - Phone:480-983-9350
Mailing Address - Fax:
Practice Address - Street 1:5520 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8793
Practice Address - Country:US
Practice Address - Phone:480-969-2783
Practice Address - Fax:480-969-3521
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11159101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ75215Medicare ID - Type UnspecifiedPROVIDER NUMBER