Provider Demographics
NPI:1518341841
Name:RUSS, CASEY (MED BCBA LBA)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:MED BCBA LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2338 W ROYAL PALM RD STE J
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-9339
Mailing Address - Country:US
Mailing Address - Phone:269-612-7261
Mailing Address - Fax:
Practice Address - Street 1:2338 W ROYAL PALM RD STE J
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-9339
Practice Address - Country:US
Practice Address - Phone:269-612-7261
Practice Address - Fax:480-522-3713
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBA-0270103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst