Provider Demographics
NPI:1265543649
Name:HARDISON, RUSS (MA)
Entity type:Individual
Prefix:MR
First Name:RUSS
Middle Name:
Last Name:HARDISON
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 1:2592 KWINA RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9278
Mailing Address - Country:US
Mailing Address - Phone:360-384-0464
Mailing Address - Fax:360-384-2336
Practice Address - Street 1:2665 KWINA RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9291
Practice Address - Country:US
Practice Address - Phone:360-312-2115
Practice Address - Fax:360-380-6976
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00007994101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health