Provider Demographics
NPI:1295353951
Name:DR PAM RUSSELL SERVICES
Entity type:Organization
Organization Name:DR PAM RUSSELL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:THD
Authorized Official - Phone:904-830-0737
Mailing Address - Street 1:752 BLANDING BLVD STE 131
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5796
Mailing Address - Country:US
Mailing Address - Phone:904-830-0737
Mailing Address - Fax:
Practice Address - Street 1:752 BLANDING BLVD STE 131
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-5796
Practice Address - Country:US
Practice Address - Phone:904-830-0737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-09
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty