Provider Demographics
NPI:1861813628
Name:RUSSELL, ROBERT (EDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 WOODLAWN PARK DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2762
Mailing Address - Country:US
Mailing Address - Phone:810-252-0443
Mailing Address - Fax:
Practice Address - Street 1:1009 WOODLAWN PARK DR
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2762
Practice Address - Country:US
Practice Address - Phone:810-252-0443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-21
Last Update Date:2013-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICC-1C4740407757103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool