Provider Demographics
NPI:1992179535
Name:RUSSELL, KELLY MARIE SPEGEL (PHD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE SPEGEL
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 GEZON PKWY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9542
Mailing Address - Country:US
Mailing Address - Phone:616-773-2908
Mailing Address - Fax:616-532-3046
Practice Address - Street 1:1055 GEZON PKWY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9542
Practice Address - Country:US
Practice Address - Phone:616-773-2908
Practice Address - Fax:616-532-3046
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016993103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist