Provider Demographics
NPI:1538793856
Name:RUSSELL, TAMEKIO
Entity type:Individual
Prefix:
First Name:TAMEKIO
Middle Name:
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 1:2072 SW SANDLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-9752
Mailing Address - Country:US
Mailing Address - Phone:503-702-6560
Mailing Address - Fax:
Practice Address - Street 1:2072 SW SANDLEWOOD PL
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-9752
Practice Address - Country:US
Practice Address - Phone:503-702-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness