Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 6301005159 | MI |
Y | 103T00000X | Psychologist | 6301005159 | MI |
N | 103G00000X | Clinical Psychologist | 6301005159 | MI |
N | 103TC0700X | Clinical Psychologist | 6301005159 | MI |
N | 103TC1900X | Counseling Psychologist | 6301005159 | MI |
N | 103TF0000X | Family Psychologist | 6301005159 | MI |
N | 103TR0400X | Rehabilitation Psychologist | 6301005159 | MI |
NPI | 1578594503 |
---|---|
Provider Name | Dr. Russell Edwin Scabbo |
First Address | Alma, MI 48801-1085 |
Second Address | Alma, MI 48801-1085 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 27/05/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0N14370 | (02) | MI |
680B945070 | BLUE CROSS BLUE SHIELD (01) | MI |