Provider Demographics
NPI:1255312187
Name:COULTER-KERN, RUSSELL GLENDON (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:GLENDON
Last Name:COULTER-KERN
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 1:1604 W HECKATHORN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH MANCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46962-2217
Mailing Address - Country:US
Mailing Address - Phone:260-982-9383
Mailing Address - Fax:
Practice Address - Street 1:1118 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:NORTH MANCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46962-1001
Practice Address - Country:US
Practice Address - Phone:260-982-5349
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040896A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist