Provider Demographics
NPI:1972646313
Name:RUSSNER, WILLIAM E (PHD LLP)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:E
Last Name:RUSSNER
Suffix:
Gender:M
Credentials:PHD LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12978 JAMES ST STE 10
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424
Mailing Address - Country:US
Mailing Address - Phone:616-399-7005
Mailing Address - Fax:616-399-7150
Practice Address - Street 1:12978 JAMES ST STE 10
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-399-7005
Practice Address - Fax:616-399-7150
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011778103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical