Provider Demographics
NPI:1639269400
Name:RUSSELL, MICHAEL JOSEPH (MA MFT, INTERN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MA MFT, INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7353 ELLENA W UNIT 195
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-8383
Mailing Address - Country:US
Mailing Address - Phone:626-272-4492
Mailing Address - Fax:
Practice Address - Street 1:211 W COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1810
Practice Address - Country:US
Practice Address - Phone:714-447-7000
Practice Address - Fax:714-447-7003
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 45505106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist