Provider Demographics
NPI:1871123448
Name:RUSSELL, DEVIN IRENE
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:IRENE
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 1:1409 KEMPSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-8134
Mailing Address - Country:US
Mailing Address - Phone:757-416-5290
Mailing Address - Fax:
Practice Address - Street 1:1409 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-8134
Practice Address - Country:US
Practice Address - Phone:757-416-5290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002506103K00000X
VARBT-19-96593106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician