Provider Demographics
NPI:1700842903
Name:HIBLER, RUSSELL J (PHD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:HIBLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:857 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4800
Mailing Address - Country:US
Mailing Address - Phone:410-244-0227
Mailing Address - Fax:866-695-6454
Practice Address - Street 1:857 PARK AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-4800
Practice Address - Country:US
Practice Address - Phone:410-244-0227
Practice Address - Fax:866-695-6454
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01803103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD229951800Medicaid
MD284608YRSKMedicare PIN
MD229951800Medicaid