Provider Demographics
NPI:1457455792
Name:FRY, RUSSELL T I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:T
Last Name:FRY
Suffix:I
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 COURT STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360
Mailing Address - Country:US
Mailing Address - Phone:508-746-8004
Mailing Address - Fax:508-746-8099
Practice Address - Street 1:363 COURT STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360
Practice Address - Country:US
Practice Address - Phone:508-746-8004
Practice Address - Fax:508-746-8099
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3861103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WO3858Medicare ID - Type Unspecified