Provider Demographics
NPI:1780358572
Name:RUSSELL, PETRA
Entity type:Individual
Prefix:
First Name:PETRA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1264 E 139TH PL
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-3125
Mailing Address - Country:US
Mailing Address - Phone:918-671-0843
Mailing Address - Fax:
Practice Address - Street 1:4867 S SHERIDAN RD STE 712A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-5721
Practice Address - Country:US
Practice Address - Phone:918-205-3013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor