Provider Demographics
NPI:1518191196
Name:RUSSELL, TISHON
Entity Type:Individual
Prefix:
First Name:TISHON
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 SEAGIRT BLVD
Mailing Address - Street 2:1A
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2930
Mailing Address - Country:US
Mailing Address - Phone:718-471-4881
Mailing Address - Fax:718-337-1535
Practice Address - Street 1:13325 220TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-1636
Practice Address - Country:US
Practice Address - Phone:718-471-4881
Practice Address - Fax:718-337-1535
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health