Provider Demographics
NPI:1164477220
Name:RUSSELL, STEPHEN FORREST (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:FORREST
Last Name:RUSSELL
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 1:4700 N. HABANA AVE.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7160
Mailing Address - Country:US
Mailing Address - Phone:813-870-0392
Mailing Address - Fax:813-871-6305
Practice Address - Street 1:4700 N. HABANA AVE.
Practice Address - Street 2:SUITE 300
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7160
Practice Address - Country:US
Practice Address - Phone:813-870-0392
Practice Address - Fax:813-871-6305
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0003453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39977OtherBCBS GRP
FL73684OtherBCBS
FL73684ZMedicare ID - Type Unspecified