Provider Demographics
NPI:1003912924
Name:THOMPSON, RUSSEL L (PHD)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6502 NURSERY DR. STE 100
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904
Mailing Address - Country:US
Mailing Address - Phone:361-575-0611
Mailing Address - Fax:361-579-6913
Practice Address - Street 1:7400 BLANCO ROAD
Practice Address - Street 2:SUITE 126
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-3500
Practice Address - Country:US
Practice Address - Phone:210-699-8700
Practice Address - Fax:210-587-2454
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32230103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX32230OtherTEXAS PSYCHOLOGIST LIC #
TX32230OtherTEXAS PSYCHOLOGIST LIC #