Provider Demographics
NPI:1790059079
Name:READER, RUSSELL BURTON IV (CADC, ASMHSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:BURTON
Last Name:READER
Suffix:IV
Gender:M
Credentials:CADC, ASMHSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1975
Mailing Address - Country:US
Mailing Address - Phone:248-390-5791
Mailing Address - Fax:866-250-6455
Practice Address - Street 1:120 S MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1975
Practice Address - Country:US
Practice Address - Phone:248-390-5791
Practice Address - Fax:866-250-6455
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-03
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01119101YA0400X
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI26-3062464OtherTIN