Provider Demographics
NPI:1083014773
Name:BENJAMINRUSSACK
Entity Type:Organization
Organization Name:BENJAMINRUSSACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MFT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSSACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-497-1908
Mailing Address - Street 1:20 SHELLEY DR APT 6
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1562
Mailing Address - Country:US
Mailing Address - Phone:415-497-1908
Mailing Address - Fax:
Practice Address - Street 1:20 SHELLEY DR APT 6
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-1562
Practice Address - Country:US
Practice Address - Phone:415-497-1908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78602251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health