Provider Demographics
NPI:1851339220
Name:MASTERSON, RUSSELL (PHD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MASTERSON
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 1:878 109TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1821
Mailing Address - Country:US
Mailing Address - Phone:239-596-8416
Mailing Address - Fax:239-513-1915
Practice Address - Street 1:878 109TH AVE N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1821
Practice Address - Country:US
Practice Address - Phone:239-596-8416
Practice Address - Fax:239-513-1915
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL2435103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75199OtherBLUE CROSS BLUE SHIELD
FLP00146358OtherRAILROAD MEDICARE
FL75199Medicare PIN
FLP00146358Medicare PIN