Provider Demographics
NPI:1437866738
Name:RUSSELL, ERIC (RADT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 A ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-2331
Mailing Address - Country:US
Mailing Address - Phone:925-978-2873
Mailing Address - Fax:925-575-0411
Practice Address - Street 1:1408 A ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-2331
Practice Address - Country:US
Practice Address - Phone:925-978-2873
Practice Address - Fax:925-575-0411
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1480390922101YA0400X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)