Provider Demographics
NPI:1326142951
Name:RUSSELL, JAMES THADDEUS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THADDEUS
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 1:61 PARC PL
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-7282
Mailing Address - Country:US
Mailing Address - Phone:985-626-4363
Mailing Address - Fax:
Practice Address - Street 1:1131 S MORRISON BLVD
Practice Address - Street 2:VA OUTPATIENT CLINIC
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:985-340-2195
Practice Address - Fax:985-340-3834
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA600103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical