Provider Demographics
NPI:1437802527
Name:RUSSELL, NICHOLAS CHARLES CLARK (PHD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CHARLES CLARK
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 1:692 RAVENNA CIR
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-1625
Mailing Address - Country:US
Mailing Address - Phone:385-208-0095
Mailing Address - Fax:
Practice Address - Street 1:187 W SCHROCK RD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2890
Practice Address - Country:US
Practice Address - Phone:614-355-7500
Practice Address - Fax:614-355-7533
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08253103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical