Provider Demographics
NPI:1467972851
Name:RUSSELL, TERRANCE (DV FACILITATOR)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DV FACILITATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1259 N LOMA VISTA DR APT 1
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-2982
Mailing Address - Country:US
Mailing Address - Phone:323-413-4925
Mailing Address - Fax:
Practice Address - Street 1:1355 REDONDO AVE STE 2
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2844
Practice Address - Country:US
Practice Address - Phone:323-413-4925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional