Healthcare Provider Details

I. General information

NPI: 1851711881
Provider Name (Legal Business Name): JOHN K. RUSSELL, PH.D. A PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 PALO VERDE AVENUE SUITE 202
LONG BEACH CA
90815-3445
US

IV. Provider business mailing address

1945 PALO VERDE AVE SUITE 202
LONG BEACH CA
90815-3443
US

V. Phone/Fax

Practice location:
  • Phone: 562-799-3333
  • Fax: 562-799-3355
Mailing address:
  • Phone: 562-799-3333
  • Fax: 562-799-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY4430
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN KENNETH RUSSELL
Title or Position: PRESIDENT
Credential: PH.D
Phone: 562-799-3333