Provider Demographics
NPI:1568438497
Name:DERN, RUSSELL W (PHD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:W
Last Name:DERN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:204 COOK RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9600
Mailing Address - Country:US
Mailing Address - Phone:513-228-7800
Mailing Address - Fax:513-725-2231
Practice Address - Street 1:975 KINGSIVEW DRIVE
Practice Address - Street 2:BLDG A
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9562
Practice Address - Country:US
Practice Address - Phone:513-228-7800
Practice Address - Fax:513-228-7846
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH3444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11489916OtherCAQH
OH0630884Medicaid
OH000000012343OtherANTHEM PIN
OH0630884Medicaid
OHH364150Medicare PIN