Provider Demographics
NPI:1043565377
Name:RUSSEL, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RUSSEL
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 1:319 NW DOGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-3216
Mailing Address - Country:US
Mailing Address - Phone:425-373-1315
Mailing Address - Fax:
Practice Address - Street 1:319 NW DOGWOOD ST
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3216
Practice Address - Country:US
Practice Address - Phone:425-373-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002826235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist