Provider Demographics
NPI:1992856652
Name:RICHARD, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:RICHARD
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 1:333 DR MICHAEL DEBAKEY DR STE 220
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5888
Mailing Address - Country:US
Mailing Address - Phone:337-478-9331
Mailing Address - Fax:337-478-9828
Practice Address - Street 1:333 DR MICHAEL DEBAKEY DR STE 220
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5888
Practice Address - Country:US
Practice Address - Phone:337-478-9331
Practice Address - Fax:337-478-9828
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX292861041C0700X
LA142191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2443640Medicaid
LA3885727Medicaid
TX144384801Medicaid