Provider Demographics
NPI:1952929945
Name:RUSSELL, PAMELA (TH D)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:TH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 BLANDING BLVD STE 131
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-5796
Mailing Address - Country:US
Mailing Address - Phone:904-830-0737
Mailing Address - Fax:904-272-6037
Practice Address - Street 1:752 BLANDING BLVD STE 131
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-5796
Practice Address - Country:US
Practice Address - Phone:904-830-0737
Practice Address - Fax:904-272-6037
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral