Provider Demographics
NPI:1831503929
Name:MCDOWELL, RUSS C SR
Entity type:Individual
Prefix:
First Name:RUSS
Middle Name:C
Last Name:MCDOWELL
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5494 PONY EXPRESS TRAIL
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709
Mailing Address - Country:US
Mailing Address - Phone:530-644-3758
Mailing Address - Fax:530-644-3782
Practice Address - Street 1:5494 PONY EXPRESS TRAIL
Practice Address - Street 2:
Practice Address - City:POLLOCK PINES
Practice Address - State:CA
Practice Address - Zip Code:95726
Practice Address - Country:US
Practice Address - Phone:530-644-3758
Practice Address - Fax:530-644-3782
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA051168174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051168OtherADDICTION COUNSELOR CERTIFICATION BOARD OF CALIFORNIA