Healthcare Provider Details

I. General information

NPI: 1518942770
Provider Name (Legal Business Name): MARK CHARLES RUSSELL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USNH YOKOSUKA JAPAN PSC 475 BOX 1
FPO AP
96350
JP

IV. Provider business mailing address

USNH YOKOSUKA JAPAN PSC 475 BOX 1
FPO AP
96350
JP

V. Phone/Fax

Practice location:
  • Phone: 11-814-6816
  • Fax:
Mailing address:
  • Phone: 2534562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPY00002607
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY00002607
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00002607
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY00002607
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY00002607
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPY00002607
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY00002607
License Number StateWA
# 8
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberPY00002607
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: