Provider Demographics
NPI:1801290770
Name:RUSSACK, BENJAMIN DAVID (MFT)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:RUSSACK
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 FOURTH STREET
Mailing Address - Street 2:201
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901
Mailing Address - Country:US
Mailing Address - Phone:415-497-1908
Mailing Address - Fax:
Practice Address - Street 1:711 FOURTH STREET
Practice Address - Street 2:201
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901
Practice Address - Country:US
Practice Address - Phone:415-497-1908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78602106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist