Provider Demographics
NPI:1609657840
Name:RUSSELL, ABBY
Entity type:Individual
Prefix:
First Name:ABBY
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 1:9117 GLENARDEN PKWY
Mailing Address - Street 2:
Mailing Address - City:GLENARDEN
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2672
Mailing Address - Country:US
Mailing Address - Phone:301-332-4188
Mailing Address - Fax:
Practice Address - Street 1:9117 GLENARDEN PKWY
Practice Address - Street 2:
Practice Address - City:GLENARDEN
Practice Address - State:MD
Practice Address - Zip Code:20706-2672
Practice Address - Country:US
Practice Address - Phone:301-332-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-23-303876106S00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician