Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PY00002607 | WA |
N | 103T00000X | Psychologist | PY00002607 | WA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | PY00002607 | WA |
N | 103TB0200X | Cognitive & Behavioral Psychologist | PY00002607 | WA |
N | 103G00000X | Clinical Psychologist | PY00002607 | WA |
N | 103TC0700X | Clinical Psychologist | PY00002607 | WA |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | PY00002607 | WA |
N | 103TH0100X | Health Service | PY00002607 | WA |
N | 103TM1800X | Intellectual & Developmental Disabilities | PY00002607 | WA |
N | 103TP2701X | Group Psychotherapist | PY00002607 | WA |
NPI | 1518942770 |
---|---|
Provider Name | Dr. Mark Charles Russell |
First Address | Fpo, AP 96350 |
Second Address | Fpo, AP 96350 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2005 |
Last Update Date | 08/07/2007 |