Provider Demographics
NPI:1275945511
Name:RUSSELL, STACEY (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 S LOOP 336 W STE 500
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3315
Mailing Address - Country:US
Mailing Address - Phone:936-647-3500
Mailing Address - Fax:
Practice Address - Street 1:2006 S LOOP 336 W STE 500
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304
Practice Address - Country:US
Practice Address - Phone:936-647-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ66972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry