Provider Demographics
NPI:1811916778
Name:SMITH, RUSSELL JOSEPH (PHD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JOSEPH
Last Name:SMITH
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 1:3478 CATCLAW DR
Mailing Address - Street 2:112
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-8224
Mailing Address - Country:US
Mailing Address - Phone:325-370-9541
Mailing Address - Fax:
Practice Address - Street 1:3478 CATCLAW DR
Practice Address - Street 2:112
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-8224
Practice Address - Country:US
Practice Address - Phone:325-370-9541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30586103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC5759OtherBCBS
TX8C5759Medicare ID - Type Unspecified
TXS14453Medicare UPIN