Provider Demographics
NPI:1861725160
Name:HARDESTY, RUSSELL A (PHD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:HARDESTY
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 1:807 COUNTY ROAD 281
Mailing Address - Street 2:
Mailing Address - City:AUXVASSE
Mailing Address - State:MO
Mailing Address - Zip Code:65231-1128
Mailing Address - Country:US
Mailing Address - Phone:573-387-4528
Mailing Address - Fax:573-387-4849
Practice Address - Street 1:807 COUNTY ROAD 281
Practice Address - Street 2:
Practice Address - City:AUXVASSE
Practice Address - State:MO
Practice Address - Zip Code:65231-1128
Practice Address - Country:US
Practice Address - Phone:573-387-4528
Practice Address - Fax:573-387-4849
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001224101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496746801Medicaid