Provider Demographics
NPI:1396746947
Name:RUSSELL, ROGER A (PHD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:RUSSELL
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 1:1049 N 3RD ST
Mailing Address - Street 2:STE 505
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-5833
Mailing Address - Country:US
Mailing Address - Phone:325-672-8883
Mailing Address - Fax:325-675-5833
Practice Address - Street 1:1049 N 3RD ST
Practice Address - Street 2:STE 505
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-5833
Practice Address - Country:US
Practice Address - Phone:325-672-8883
Practice Address - Fax:325-675-5833
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2-2996103T00000X
TX873LMFT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0971830-01Medicaid
TX00A16LMedicare ID - Type Unspecified