Provider Demographics
NPI:1407983109
Name:RUSSIKOFF, LYNN
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:RUSSIKOFF
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 1:40925 COUNTY CENTER DR STE 100&200
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-6054
Mailing Address - Country:US
Mailing Address - Phone:951-600-6360
Mailing Address - Fax:951-600-6377
Practice Address - Street 1:40925 COUNTY CENTER DR STE 100&200
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6054
Practice Address - Country:US
Practice Address - Phone:951-600-6360
Practice Address - Fax:951-600-6377
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA77874101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)