Provider Demographics
NPI:1356053565
Name:TOLL, RUSSELL TENNYSON (PHD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:TENNYSON
Last Name:TOLL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 E SOUTHLAKE BLVD STE 222
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7065
Mailing Address - Country:US
Mailing Address - Phone:817-888-6974
Mailing Address - Fax:
Practice Address - Street 1:771 E SOUTHLAKE BLVD STE 222
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7065
Practice Address - Country:US
Practice Address - Phone:817-888-6974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZB0301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherBiomedical Engineering
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist