Provider Demographics
NPI:1063660926
Name:RUSSELL, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:RUSSELL
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 1:40 W YAVAPAI ST
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-3201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1090 S VULTURE MINE RD
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-3145
Practice Address - Country:US
Practice Address - Phone:928-684-6600
Practice Address - Fax:928-684-6628
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool