Healthcare Provider Details

I. General information

NPI: 1639579675
Provider Name (Legal Business Name): MR. THOMAS RUSSELL II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 KILROY AIRPORT WAY
LONG BEACH CA
90806-2457
US

IV. Provider business mailing address

15281 DEERWOOD LN
FONTANA CA
92336-0774
US

V. Phone/Fax

Practice location:
  • Phone: 562-424-6015
  • Fax: 562-988-6897
Mailing address:
  • Phone: 909-899-6095
  • Fax: 909-899-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number94020370
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number94020370
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number101067938
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number76881
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: