Provider Demographics
NPI:1184943649
Name:RUSSELL, STEVEN G (MA)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:G
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 OAK KNOLL RD
Mailing Address - Street 2:
Mailing Address - City:ATCO
Mailing Address - State:NJ
Mailing Address - Zip Code:08004-1137
Mailing Address - Country:US
Mailing Address - Phone:856-719-1989
Mailing Address - Fax:
Practice Address - Street 1:620 OAK KNOLL RD
Practice Address - Street 2:
Practice Address - City:ATCO
Practice Address - State:NJ
Practice Address - Zip Code:08004-1137
Practice Address - Country:US
Practice Address - Phone:856-719-1989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4140206Medicaid