Provider Demographics
NPI:1518942770
Name:RUSSELL, MARK CHARLES (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHARLES
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:USNH YOKOSUKA JAPAN
Mailing Address - Street 2:PSC 475 BOX 1
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96350
Mailing Address - Country:JP
Mailing Address - Phone:253-4562
Mailing Address - Fax:
Practice Address - Street 1:USNH YOKOSUKA JAPAN
Practice Address - Street 2:PSC 475 BOX 1
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96350
Practice Address - Country:JP
Practice Address - Phone:011-814-6816
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002607103TA0400X, 103TB0200X, 103TC0700X, 103TC2200X, 103TH0100X, 103TM1800X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy