Provider Demographics
NPI:1679680094
Name:DEAN, RUSSELL MARTIN (LPC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:MARTIN
Last Name:DEAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 ROYAL VIEW CT
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76087-7356
Mailing Address - Country:US
Mailing Address - Phone:817-441-5711
Mailing Address - Fax:817-536-1556
Practice Address - Street 1:2701 BURCHILL RD N
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-3012
Practice Address - Country:US
Practice Address - Phone:817-534-0814
Practice Address - Fax:817-536-1556
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14412101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health