Provider Demographics
NPI:1518279215
Name:RUSSELL, MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 W 24TH ST APT 3H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1206
Mailing Address - Country:US
Mailing Address - Phone:121-261-3128
Mailing Address - Fax:212-242-4088
Practice Address - Street 1:4951 CHAMBERS STREET - 6TH FLOOR
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10007-1209
Practice Address - Country:US
Practice Address - Phone:121-261-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004023-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist