Provider Demographics
NPI:1346701661
Name:BYERS, RUSSELL DAVID
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DAVID
Last Name:BYERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SHIPPING PL
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21222-4318
Mailing Address - Country:US
Mailing Address - Phone:410-282-5401
Mailing Address - Fax:
Practice Address - Street 1:23 SHIPPING PL
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-4318
Practice Address - Country:US
Practice Address - Phone:410-282-5401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty