Provider Demographics
NPI:1639701741
Name:HATCH, RUSSELL (CCMA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:HATCH
Suffix:
Gender:M
Credentials:CCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 SAN MARCUS DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-7355
Mailing Address - Country:US
Mailing Address - Phone:707-580-5142
Mailing Address - Fax:
Practice Address - Street 1:368 SAN MARCUS DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-7355
Practice Address - Country:US
Practice Address - Phone:707-580-5142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician