Provider Demographics
NPI:1629306162
Name:RUSSELL, ANTHONY R
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:R
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 1:6903 OAKMONT AVE SE
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-8716
Mailing Address - Country:US
Mailing Address - Phone:425-999-6127
Mailing Address - Fax:
Practice Address - Street 1:6903 OAKMONT AVE SE
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065-8716
Practice Address - Country:US
Practice Address - Phone:425-999-6127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC60069117101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health