Provider Demographics
NPI:1770032302
Name:MARJORIE RUSSELL NP IN PSYCHIATRY, PLLC
Entity Type:Organization
Organization Name:MARJORIE RUSSELL NP IN PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:518-389-6606
Mailing Address - Street 1:36 BRITISH AMERICAN BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1410
Mailing Address - Country:US
Mailing Address - Phone:518-389-6606
Mailing Address - Fax:518-389-6605
Practice Address - Street 1:36 BRITISH AMERICAN BLVD
Practice Address - Street 2:STE 102
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1410
Practice Address - Country:US
Practice Address - Phone:518-389-6606
Practice Address - Fax:518-389-6605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401959-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty