Provider Demographics
NPI:1851767974
Name:RUSSELL, CLEMENT STREET (PSYD)
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:STREET
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 LILY CREEK RD
Mailing Address - Street 2:#201
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2815
Mailing Address - Country:US
Mailing Address - Phone:502-338-0608
Mailing Address - Fax:502-245-1888
Practice Address - Street 1:912 LILY CREEK RD
Practice Address - Street 2:#201
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2815
Practice Address - Country:US
Practice Address - Phone:502-338-0608
Practice Address - Fax:502-245-1888
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY170475103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical