Basic Information
| Provider Information | |||||||||
| NPI: | 1730268236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | STE. 590 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 405 W 5TH ST | ||||||||
| Address2: | STE. 590 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345015 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | MFC30464 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.