Provider Demographics
NPI:1245577378
Name:RUSSELL, KENNETH LADON
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LADON
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 SPRINGHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5021
Mailing Address - Country:US
Mailing Address - Phone:405-245-1303
Mailing Address - Fax:
Practice Address - Street 1:11000 SPRINGHOLLOW RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5021
Practice Address - Country:US
Practice Address - Phone:405-245-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health