Provider Demographics
NPI:1346310869
Name:SEIGENBERG, RUSSELL DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:DAVID
Last Name:SEIGENBERG
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 283
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-0283
Mailing Address - Country:US
Mailing Address - Phone:435-764-3206
Mailing Address - Fax:435-752-0226
Practice Address - Street 1:191 E 450 N
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-8400
Practice Address - Country:US
Practice Address - Phone:435-764-3206
Practice Address - Fax:435-752-0226
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1141192501103T00000X, 103TC1900X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT100001424477OtherREGENCE BLUECROSS BLUESHIELD
UT1200415OtherDESERET MUTUAL BENEFIT ADMISTRATION
UT1346310869OtherUNITED HEALTHCARE
UT100001424477OtherREGENCE BLUECROSS BLUESHIELD
UTR86091Medicare UPIN