Provider Demographics
NPI:1629347307
Name:BARD, RUSSELL S JR
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:S
Last Name:BARD
Suffix:JR
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 1:311 LOWELL ST
Mailing Address - Street 2:APT 2101
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 LOWELL ST
Practice Address - Street 2:APT 2101
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4552
Practice Address - Country:US
Practice Address - Phone:978-873-7653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst