Basic Information
| Provider Information | |||||||||
| NPI: | 1861740102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1268 | ||||||||
| Address2: | |||||||||
| City: | CAPITOLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950101268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8312040232 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 542 OCEAN ST | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950606622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314590444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2012 | ||||||||
| LastUpdateDate: | 03/07/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | IMF 64743 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.