Provider Demographics
NPI:1508278185
Name:RUSSELL, JULIE (PSYD)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 E MYRTLE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4850
Mailing Address - Country:US
Mailing Address - Phone:801-369-8989
Mailing Address - Fax:801-704-9741
Practice Address - Street 1:154 E MYRTLE AVE STE 204
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4850
Practice Address - Country:US
Practice Address - Phone:801-369-8989
Practice Address - Fax:801-704-9741
Is Sole Proprietor?:No
Enumeration Date:2014-05-29
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12857677-2504103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical