Provider Demographics
NPI:1477087625
Name:RUSSELL, BRADLEY NELSON
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:NELSON
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1650
Mailing Address - Country:US
Mailing Address - Phone:619-440-4801
Mailing Address - Fax:619-442-1592
Practice Address - Street 1:1364 JOHNSON AVE. SUITE 111
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:619-440-4801
Practice Address - Fax:619-442-1592
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)