Provider Demographics
NPI:1033450218
Name:DELGADO, RUSSELL JAMES
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JAMES
Last Name:DELGADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 N GRAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1552
Mailing Address - Country:US
Mailing Address - Phone:626-967-1667
Mailing Address - Fax:
Practice Address - Street 1:1126 N GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1552
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF67987101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health