Provider Demographics
NPI:1114125200
Name:DORE, RUSSELL LEE (EDD, LP)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:LEE
Last Name:DORE
Suffix:
Gender:M
Credentials:EDD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E MAIN ST
Mailing Address - Street 2:#201
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1681
Mailing Address - Country:US
Mailing Address - Phone:248-348-1100
Mailing Address - Fax:248-348-3410
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:#201
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1681
Practice Address - Country:US
Practice Address - Phone:248-348-1100
Practice Address - Fax:248-348-3410
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301001278103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI143449OtherVALUE OPTIONS
MI68OH201330OtherBC/BS OF MICHIGAN