Provider Demographics
NPI:1326040148
Name:RUSSELL, GERALD LEE (PHD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LEE
Last Name:RUSSELL
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:PO BOX 1705
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-1705
Mailing Address - Country:US
Mailing Address - Phone:505-454-2202
Mailing Address - Fax:505-454-2211
Practice Address - Street 1:713 6TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4359
Practice Address - Country:US
Practice Address - Phone:505-429-4679
Practice Address - Fax:505-425-3370
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM761103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM76705Medicaid