Provider Demographics
NPI:1902939572
Name:RUSSELL, STEPHEN REED (PHD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:REED
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 MEDICAL PARK LOOP
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-5222
Mailing Address - Country:US
Mailing Address - Phone:828-631-3973
Mailing Address - Fax:828-631-9280
Practice Address - Street 1:154 MEDICAL PARK LOOP
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-5222
Practice Address - Country:US
Practice Address - Phone:828-631-3973
Practice Address - Fax:828-631-9280
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3330103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist