Provider Demographics
NPI:1720188790
Name:RUSSELL, KATHRYN JANE (MFT)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:JANE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:JANE
Other - Last Name:RUSSELL-GRAFIUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:24721 SPRING RD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9635
Mailing Address - Country:US
Mailing Address - Phone:909-423-0860
Mailing Address - Fax:
Practice Address - Street 1:5029 LAMART DR
Practice Address - Street 2:#6
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0605
Practice Address - Country:US
Practice Address - Phone:951-369-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMX1557106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist