Active NPI
Juanita Gwendolyn Russell, MFT
- Marriage & Family Therapist
- Santa Rosa, CA
National Provider Identifier
1497851174
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Marriage & Family Therapist
- License
- 29702
- Practice address
- 4527 Montgomery Dr
#F
Santa Rosa, CA 95409 - Phone
- (707) 547-0567
- Fax
- (707) 539-7096
- NPI assigned
- Sep 16, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Marriage & Family Therapist | 106H00000X | 29702 | CA | Primary |
Addresses
Primary practice location
4527 Montgomery Dr
#F
Santa Rosa, CA 95409
Mailing address
4527 Montgomery Dr
#F
Santa Rosa, CA 95409
Phone (707) 547-0567
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Jan 1, 2024 through Jan 1, 2028
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 29702 | CA | MD | Chiropractor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158364800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1497851174",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4527 MONTGOMERY DR",
"address_2": "#F",
"city": "SANTA ROSA",
"state": "CA",
"postal_code": "95409",
"telephone_number": "707-547-0567",
"fax_number": "707-539-7096"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4527 MONTGOMERY DR",
"address_2": "#F",
"city": "SANTA ROSA",
"state": "CA",
"postal_code": "95409",
"telephone_number": "707-547-0567",
"fax_number": "707-539-7096"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSELL",
"first_name": "JUANITA",
"middle_name": "GWENDOLYN",
"credential": "MFT",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-09-16",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "106H00000X",
"taxonomy_group": "",
"desc": "Marriage & Family Therapist",
"state": "CA",
"license": "29702",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Santa Rosa, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.