Provider Demographics
NPI:1568422095
Name:CROUSE, RUSSELL DEWARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:DEWARD
Last Name:CROUSE
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 1:7516 ENTERPRISE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138
Mailing Address - Country:US
Mailing Address - Phone:901-755-5802
Mailing Address - Fax:901-757-2249
Practice Address - Street 1:7516 ENTERPRISE
Practice Address - Street 2:SUITE 1
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-755-5802
Practice Address - Fax:901-757-2249
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP773103T00000X
MS29406103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3683012Medicare ID - Type Unspecified