Basic Information
| Provider Information | |||||||||
| NPI: | 1770740631 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 GILMAN DR # MC0304 | ||||||||
| Address2: | UCSD COUNSELING & PSYCHOLOGICAL SRVS | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920935004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585343755 | ||||||||
| FaxNumber: | 8585342628 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 GILMAN DR # MC0304 | ||||||||
| Address2: | UCSD COUNSELING & PSYCHOLOGICAL SRVS | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920935004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585343755 | ||||||||
| FaxNumber: | 8585342628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 05/19/2008 | ||||||||
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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 | 103T00000X | 16749 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 16749 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.