Provider Demographics
NPI:1083872642
Name:LARK, RUSSELL ELLIS (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ELLIS
Last Name:LARK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 VALLEY WEST DR
Mailing Address - Street 2:SUITE 707
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 VALLEY WEST DR
Practice Address - Street 2:SUITE 707
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1908
Practice Address - Country:US
Practice Address - Phone:515-222-1999
Practice Address - Fax:515-224-3949
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling