Provider Demographics
NPI:1407274475
Name:RUSSELL, TAMARA S
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 COACHLIGHT DR APT A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-7854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:214 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-6506
Practice Address - Country:US
Practice Address - Phone:405-272-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-06
Last Update Date:2014-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health