Provider Demographics
NPI:1578626586
Name:HABER, RUSSELL (PHD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:HABER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 BULL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2506
Mailing Address - Country:US
Mailing Address - Phone:803-254-3786
Mailing Address - Fax:
Practice Address - Street 1:1816 BULL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2506
Practice Address - Country:US
Practice Address - Phone:803-254-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC316103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0048Medicaid
Q3212625099Medicare UPIN