Provider Demographics
NPI:1740214865
Name:RUSSELL, MARLA SUE (PHD)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:SUE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 STATE LINE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-2019
Mailing Address - Country:US
Mailing Address - Phone:816-363-5600
Mailing Address - Fax:816-363-5159
Practice Address - Street 1:8301 STATE LINE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-2019
Practice Address - Country:US
Practice Address - Phone:816-363-5600
Practice Address - Fax:816-363-5159
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS944103T00000X
MOPY01033103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499071900Medicaid
R55178Medicare UPIN