Provider Demographics
NPI:1770740631
Name:RUSSELL, PETER CHRISTIAN (PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHRISTIAN
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 1:9500 GILMAN DR # MC0304
Mailing Address - Street 2:UCSD COUNSELING & PSYCHOLOGICAL SRVS
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-5004
Mailing Address - Country:US
Mailing Address - Phone:858-534-3755
Mailing Address - Fax:858-534-2628
Practice Address - Street 1:9500 GILMAN DR # MC0304
Practice Address - Street 2:UCSD COUNSELING & PSYCHOLOGICAL SRVS
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-5004
Practice Address - Country:US
Practice Address - Phone:858-534-3755
Practice Address - Fax:858-534-2628
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16749103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical