Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 25489 | CA |
NPI | 1003050683 |
---|---|
Provider Name | Marc Richard Russak |
First Address | Los Angeles, CA 90024-2925 |
Second Address | Los Angeles, CA 90024-2925 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2009 |
Last Update Date | 27/04/2009 |