Provider Demographics
NPI:1215219720
Name:RUSSELL, KIRK HODARI (BHRS)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:HODARI
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 2ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-8075
Mailing Address - Country:US
Mailing Address - Phone:580-465-9293
Mailing Address - Fax:
Practice Address - Street 1:32 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-7013
Practice Address - Country:US
Practice Address - Phone:580-226-5209
Practice Address - Fax:580-226-5219
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid