Provider Demographics
NPI:1902039449
Name:LILES, RUSSELL LEE
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:LEE
Last Name:LILES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8801 HORIZON BLVD NE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1533
Mailing Address - Country:US
Mailing Address - Phone:505-798-5704
Mailing Address - Fax:505-798-5682
Practice Address - Street 1:8801 HORIZON BLVD NE
Practice Address - Street 2:SUITE 260
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1533
Practice Address - Country:US
Practice Address - Phone:505-798-5704
Practice Address - Fax:505-798-5682
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor