Provider Demographics
NPI:1881076396
Name:REED, RUSSELL
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:REED
Suffix:
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-0699
Mailing Address - Country:US
Mailing Address - Phone:530-957-0403
Mailing Address - Fax:
Practice Address - Street 1:4250 FOWLER LN STE 204
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9782
Practice Address - Country:US
Practice Address - Phone:530-626-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-19
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CA1007861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker