Provider Demographics
NPI:1255304887
Name:RUSSELL, MICHAEL LEE SR (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:RUSSELL
Suffix:SR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 OTTER POND PLACE
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4011
Mailing Address - Country:US
Mailing Address - Phone:254-294-5605
Mailing Address - Fax:757-788-2962
Practice Address - Street 1:2525 NORTH LOOP WEST
Practice Address - Street 2:SUITE 400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008
Practice Address - Country:US
Practice Address - Phone:832-394-1440
Practice Address - Fax:832-394-1448
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPY00002256103G00000X, 103TC0700X
TX38306103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist