Provider Demographics
NPI:1508061516
Name:RUSSELL, PENELOPE LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PENELOPE
Middle Name:LOUISE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3373 DWIGHT WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2522
Mailing Address - Country:US
Mailing Address - Phone:510-981-1037
Mailing Address - Fax:
Practice Address - Street 1:5325 BRODER BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-3309
Practice Address - Country:US
Practice Address - Phone:925-551-6737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic