Provider Demographics
NPI:1669079059
Name:HENDRICKS, RUSSELL G
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:G
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RUSTY
Other - Middle Name:G
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:130 SOUTHERN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-3223
Mailing Address - Country:US
Mailing Address - Phone:606-679-4782
Mailing Address - Fax:606-678-5296
Practice Address - Street 1:259 PARKERS MILL RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3152
Practice Address - Country:US
Practice Address - Phone:606-679-4782
Practice Address - Fax:606-679-4097
Is Sole Proprietor?:No
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)