Provider Demographics
NPI:1659512978
Name:RUSSELL, KEVIN (MFT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6607
Mailing Address - Country:US
Mailing Address - Phone:707-523-4160
Mailing Address - Fax:
Practice Address - Street 1:1030 2ND ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6607
Practice Address - Country:US
Practice Address - Phone:707-523-4160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25095106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XMedicare PIN