Provider Demographics
NPI:1942334578
Name:LLEWELLYN, RUSSELL CHANDLER (PH D)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:CHANDLER
Last Name:LLEWELLYN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-0022
Mailing Address - Country:US
Mailing Address - Phone:650-595-4500
Mailing Address - Fax:
Practice Address - Street 1:1350 CHERRY ST
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-3008
Practice Address - Country:US
Practice Address - Phone:650-595-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4609103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical