Provider Demographics
NPI:1932352275
Name:RUSSELL, HEATHER ANN (PSYD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 TUDOR CENTRE DR
Mailing Address - Street 2:SUITE #320
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5904
Mailing Address - Country:US
Mailing Address - Phone:907-729-8624
Mailing Address - Fax:907-729-8607
Practice Address - Street 1:4155 TUDOR CENTRE DR
Practice Address - Street 2:SUITE #103
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5902
Practice Address - Country:US
Practice Address - Phone:907-729-8624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK581103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPS2781Medicaid
AK8EF689Medicare PIN
AKPS2781Medicaid
AK8EI246Medicare PIN
AK8EK903Medicare PIN