Provider Demographics
NPI:1881614519
Name:RUSSELL, MICHELE C (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:C
Last Name:RUSSELL
Suffix:
Gender:F
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:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:AHWAHNEE
Mailing Address - State:CA
Mailing Address - Zip Code:93601-0357
Mailing Address - Country:US
Mailing Address - Phone:559-908-1516
Mailing Address - Fax:559-642-6990
Practice Address - Street 1:3313 N HILLIARD ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-5854
Practice Address - Country:US
Practice Address - Phone:559-227-4810
Practice Address - Fax:559-227-4167
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20822103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL208220OtherMEDICARE PTAN
CAPSY208220OtherMEDICAID PROVIDER NUMBER
PSY20822OtherCA LICENSE NUMBER