Provider Demographics
NPI:1407858988
Name:RUSSELL, SCOT W (PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOT
Middle Name:W
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080
Mailing Address - Country:US
Mailing Address - Phone:650-742-3841
Mailing Address - Fax:650-742-2591
Practice Address - Street 1:1200 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080
Practice Address - Country:US
Practice Address - Phone:650-742-3841
Practice Address - Fax:650-742-2591
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2009-05-12
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
UT1140332501103TB0200X
CAPSY 22480103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000012077Medicare ID - Type Unspecified
UTR56071Medicare UPIN