Provider Demographics
NPI:1386842664
Name:CARROLL, RUSSELL THOMAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:THOMAS
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:RUSSELL
Other - Middle Name:THOMAS
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-8693
Mailing Address - Fax:210-916-6679
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-8693
Practice Address - Fax:210-916-6679
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist