Provider Demographics
NPI:1558415703
Name:WILKIE, RUSSELL (MFT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:WILKIE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110372
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95011-0372
Mailing Address - Country:US
Mailing Address - Phone:408-529-1975
Mailing Address - Fax:
Practice Address - Street 1:901 CAMPISI WAY
Practice Address - Street 2:STE 350
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2339
Practice Address - Country:US
Practice Address - Phone:408-529-1975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29758106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1558415703OtherNATIONAL PROVIDER NUMBER