Provider Demographics
NPI:1083287809
Name:RUSSELL, LAURIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9939 HIGHWAY 151
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9939 HIGHWAY 151
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1900
Practice Address - Country:US
Practice Address - Phone:210-706-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38677103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical