Provider Demographics
NPI:1467190777
Name:RUSSELL, THOMAS MICHAEL JR (BA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:MR
Other - First Name:THOMAS
Other - Middle Name:MICHAEL
Other - Last Name:RUSSELL
Other - Suffix:JR
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:211 WESTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-8682
Mailing Address - Country:US
Mailing Address - Phone:502-553-5746
Mailing Address - Fax:
Practice Address - Street 1:5966 SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-0387
Practice Address - Country:US
Practice Address - Phone:270-904-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYU8171581502OtherCIGNA