Basic Information
Provider Information | |||||||||
NPI: | 1639269400 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUSSELL | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | JOSEPH | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A. MFT, INTERN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7353 ELLENA W UNIT 195 | ||||||||
Address2: |   | ||||||||
City: | RANCHO CUCAMONGA | ||||||||
State: | CA | ||||||||
PostalCode: | 917308383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6262724492 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 211 W COMMONWEALTH AVE | ||||||||
Address2: |   | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928321810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144477000 | ||||||||
FaxNumber: | 7144477003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 45505 | CA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.