Provider Demographics
NPI:1376632216
Name:MENARD, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MENARD
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:BLDG 415
Mailing Address - Street 2:CORNER OF 31ST ST AND 761ST TANK BN
Mailing Address - City:FORT CAVAZOS
Mailing Address - State:TX
Mailing Address - Zip Code:76544
Mailing Address - Country:US
Mailing Address - Phone:254-618-8837
Mailing Address - Fax:
Practice Address - Street 1:590 MEDICAL CENTER ROAD
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS,
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-618-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX612121041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical