Provider Demographics
NPI:1568839298
Name:RUSSELL, KATHERINE (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 BROADWAY #2
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139
Mailing Address - Country:US
Mailing Address - Phone:508-280-2260
Mailing Address - Fax:
Practice Address - Street 1:10 FEDERAL STREET, SUITE 307
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-5402
Practice Address - Country:US
Practice Address - Phone:617-758-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA11135103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program