Individual
MRS. TISA BERNALLY-RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
BSW, LSAA
Contact information
Practice address
101 W BROADWAY, SUITE D, FARMINGTON, NM 87401-6419
(505) 327-4796
Mailing address
PO BOX 3239, 101 W. BROADWAY, SUITE D, FARMINGTON, NM 87499-3239
(505) 327-4796
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
0160331
NM
Other
Enumeration date
11/13/2013
Last updated
11/13/2013
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