Provider Demographics
NPI:1578570305
Name:RUSSELL, ANITA JEANNE (EDD)
Entity Type:Individual
Prefix:DR
First Name:ANITA
Middle Name:JEANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 E 75TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6126
Mailing Address - Country:US
Mailing Address - Phone:918-671-7960
Mailing Address - Fax:918-728-8387
Practice Address - Street 1:3314 E 51ST ST
Practice Address - Street 2:SUITE 204F
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3583
Practice Address - Country:US
Practice Address - Phone:918-671-7960
Practice Address - Fax:918-728-8387
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical