Provider Demographics
NPI:1659793446
Name:MYERS, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MYERS
Suffix:
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:PO BOX 578
Mailing Address - Street 2:28545 HIGHWAY 18
Mailing Address - City:SKYFOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92385-0578
Mailing Address - Country:US
Mailing Address - Phone:909-336-1800
Mailing Address - Fax:909-336-0990
Practice Address - Street 1:28545 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:SKYFOREST
Practice Address - State:CA
Practice Address - Zip Code:92385-0578
Practice Address - Country:US
Practice Address - Phone:909-336-1800
Practice Address - Fax:909-336-0990
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)