Provider Demographics
NPI:1821203126
Name:RUSSELL, DEIRDRE KAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEIRDRE
Middle Name:KAY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:DEEDEE
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:8211 VILLAGE HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-3706
Mailing Address - Country:US
Mailing Address - Phone:704-455-2014
Mailing Address - Fax:704-896-7836
Practice Address - Street 1:8211 VILLAGE HARBOR DR
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-3706
Practice Address - Country:US
Practice Address - Phone:704-455-2014
Practice Address - Fax:704-896-7836
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2418103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000485Medicaid
NC292157000OtherMAGELLAN