Basic Information
| Provider Information | |||||||||
| NPI: | 1386843688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDLIN | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 189 | ||||||||
| Address2: | |||||||||
| City: | SAN GERONIMO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949630189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152330788 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3075 ADELINE ST. | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108481112 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 25562 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 01CR | 01 | CA | MEDICAL | OTHER |