Basic Information
| Provider Information | |||||||||
| NPI: | 1972191757 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | ONDREA | ||||||||
| MiddleName: | NECOLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSELL | ||||||||
| OtherFirstName: | YASMINE | ||||||||
| OtherMiddleName: | ONDREA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1202 MORENA BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921103842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750822 | ||||||||
| FaxNumber: | 6192327048 | ||||||||
| Practice Location | |||||||||
| Address1: | 2865 LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921132411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192750822 | ||||||||
| FaxNumber: | 6192327048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2021 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.