Individual
ANDRE RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
7 WALLACE CT APT 1, VALLEY STREAM, NY 11580-5557
(516) 557-5578
Mailing address
PO BOX 1343, VALLEY STREAM, NY 11582-1343
(516) 557-5578
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
10/17/2019
Last updated
10/17/2019
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