Provider Demographics
NPI:1134140635
Name:RUSSELL, DORIS M (PHD)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LEDGEHILL RD
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2273
Mailing Address - Country:US
Mailing Address - Phone:802-442-5491
Mailing Address - Fax:802-442-3363
Practice Address - Street 1:100 LEDGEHILL RD
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2273
Practice Address - Country:US
Practice Address - Phone:802-442-5491
Practice Address - Fax:802-442-3363
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT048-0000574103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
29292OtherBLUE CROSS
1047191OtherCIGNA
VT0VN0552Medicaid
10022260OtherCDPHP
359506OtherMANAGED HEALTH NET
359506OtherMANAGED HEALTH NET
10022260OtherCDPHP
VTVN055201Medicare PIN