Provider Demographics
NPI:1932310802
Name:DECKER, RUSS KINGMAN JR (MS)
Entity Type:Individual
Prefix:MR
First Name:RUSS
Middle Name:KINGMAN
Last Name:DECKER
Suffix:JR
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32184 COVE CIRCLE
Mailing Address - Street 2:P.O. BOX 3254
Mailing Address - City:RUNNING SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92382
Mailing Address - Country:US
Mailing Address - Phone:909-867-4879
Mailing Address - Fax:
Practice Address - Street 1:32184 COVE CIRCLE
Practice Address - Street 2:
Practice Address - City:RUNNING SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92382
Practice Address - Country:US
Practice Address - Phone:909-867-4879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51257106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist