Provider Demographics
NPI:1639579675
Name:RUSSELL, THOMAS II
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:RUSSELL
Suffix:II
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 1:15281 DEERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-0774
Mailing Address - Country:US
Mailing Address - Phone:909-899-6095
Mailing Address - Fax:909-899-6095
Practice Address - Street 1:3780 KILROY AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2457
Practice Address - Country:US
Practice Address - Phone:562-424-6015
Practice Address - Fax:562-988-6897
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94020370101YA0400X, 101YM0800X
CA101067938103TS0200X
CA76881106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool