Provider Demographics
NPI:1699810614
Name:RUSSELL, STEPHANIE SUZANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:SUZANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PSYD
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 146
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-0146
Mailing Address - Country:US
Mailing Address - Phone:541-330-2254
Mailing Address - Fax:
Practice Address - Street 1:223 SE DAVIS AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1333
Practice Address - Country:US
Practice Address - Phone:541-330-2254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1525103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114262Medicare ID - Type Unspecified