Basic Information
| Provider Information | |||||||||
| NPI: | 1669079059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDRICKS | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | G | ||||||||
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| OtherLastName: | HENDRICKS | ||||||||
| OtherFirstName: | RUSTY | ||||||||
| OtherMiddleName: | G | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 SOUTHERN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066794782 | ||||||||
| FaxNumber: | 6066785296 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 PARKERS MILL RD | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066794782 | ||||||||
| FaxNumber: | 6066794097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2020 | ||||||||
| LastUpdateDate: | 10/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.