Provider Demographics
NPI:1407234172
Name:RUSSELL, DAVID LEE JR (LCDP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 COMSTOCK AVENUE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 COMSTOCK AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1206
Practice Address - Country:US
Practice Address - Phone:401-699-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)