Provider Demographics
NPI:1144428756
Name:RUSSELL, WILLIAM (MFT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 TRAFALGAR LN
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4265
Mailing Address - Country:US
Mailing Address - Phone:949-492-2698
Mailing Address - Fax:
Practice Address - Street 1:4201 W CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-1505
Practice Address - Country:US
Practice Address - Phone:714-748-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29703106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist