Provider Demographics
NPI:1285640128
Name:RUSSELL, MICHAEL (MA, DMIN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MA, DMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 ROCK PRAIRIE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8777
Mailing Address - Country:US
Mailing Address - Phone:979-693-3393
Mailing Address - Fax:979-694-7337
Practice Address - Street 1:207 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE B
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8777
Practice Address - Country:US
Practice Address - Phone:979-693-3393
Practice Address - Fax:979-694-7337
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9957101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2809LCOtherBCBS