Provider Demographics
NPI:1548362171
Name:RUSSELL, DAVID LEE (EDD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2585
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49081-2585
Mailing Address - Country:US
Mailing Address - Phone:269-381-0150
Mailing Address - Fax:269-373-4720
Practice Address - Street 1:8036 MOORSBRIDGE ROAD
Practice Address - Street 2:SUITE #2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4417
Practice Address - Country:US
Practice Address - Phone:269-327-1438
Practice Address - Fax:269-327-6454
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006163103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OC910420OtherBCBS
OC94582OtherBCBS
MI0N39690Medicare PIN