Provider Demographics
NPI:1568670545
Name:RUSSELL, ANTHONY C
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:C
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 W GRAND BLVD
Mailing Address - Street 2:1852 W. GRAND BLVD
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1006
Mailing Address - Country:US
Mailing Address - Phone:313-894-4444
Mailing Address - Fax:313-894-1291
Practice Address - Street 1:1852 W GRAND BLVD
Practice Address - Street 2:1852 W. GRAND BLVD
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1006
Practice Address - Country:US
Practice Address - Phone:313-894-4444
Practice Address - Fax:313-894-1291
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)