Provider Demographics
NPI:1568855369
Name:RUSSELL, GILLIAN ISAACS (PHD, NCPSYA)
Entity Type:Individual
Prefix:DR
First Name:GILLIAN
Middle Name:ISAACS
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD, NCPSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ARAPAHOE AVE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5854
Mailing Address - Country:US
Mailing Address - Phone:605-431-5022
Mailing Address - Fax:
Practice Address - Street 1:100 ARAPAHOE AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5854
Practice Address - Country:US
Practice Address - Phone:605-431-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONLC.0105131102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst