Provider Demographics
NPI:1073857702
Name:RUSSELL, REBECCA JEAN (LMFT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 C AVENUE
Mailing Address - Street 2:
Mailing Address - City:CERENADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118
Mailing Address - Country:US
Mailing Address - Phone:858-248-5819
Mailing Address - Fax:
Practice Address - Street 1:2725 CONGRESS AVE STE 2C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-688-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA113464106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist