Individual
LISA EVEALINE RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
HAB SPEC
Contact information
Practice address
804 INDUSTRIAL PARK RD, MAXWELTON, WV 24957-8066
(304) 497-0500
Mailing address
PO BOX 1001, RUPERT, WV 25984-1001
(304) 646-9083
Taxonomy
Speciality
Code
Description
License number
State
373H00000X
Day Training/Habilitation Specialist
Primary
—
WV
Other
Enumeration date
06/21/2020
Last updated
06/21/2020
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