Provider Demographics
NPI:1801006010
Name:RUSSELL, DAVID MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:RUSSELL
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 1:1001 FARMINGTON AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2135
Mailing Address - Country:US
Mailing Address - Phone:860-561-4841
Mailing Address - Fax:860-561-4891
Practice Address - Street 1:1001 FARMINGTON AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2135
Practice Address - Country:US
Practice Address - Phone:860-561-4841
Practice Address - Fax:860-561-4891
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1039103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical