Provider Demographics
NPI:1265687263
Name:RUSSELL, LINDA RENEE (MA)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:RENEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-3011
Mailing Address - Country:US
Mailing Address - Phone:925-586-9022
Mailing Address - Fax:925-363-5021
Practice Address - Street 1:140 MAYHEW WAY
Practice Address - Street 2:#503
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4328
Practice Address - Country:US
Practice Address - Phone:925-586-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 38980106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist