Individual
MISS TARA NICOLE RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MS, BCBA, LBA
Contact information
Practice address
6550 E BROADWAY RD STE 110, MESA, AZ 85206-1734
(480) 672-0772
(317) 520-8200
Mailing address
7108 S KANNER HWY, STUART, FL 34997-7462
(855) 832-6727
(772) 675-9100
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
—
—
103K00000X
Behavior Analyst
Primary
BEH-000896
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1-21-48060
BCBA CERTIFICATE
—
Enumeration date
09/17/2008
Last updated
05/01/2023
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