Healthcare Provider Details

I. General information

NPI: 1144428756
Provider Name (Legal Business Name): WILLIAM RUSSELL MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 W CHAPMAN AVE
ORANGE CA
92868-1505
US

IV. Provider business mailing address

101 TRAFALGAR LN
SAN CLEMENTE CA
92672-4265
US

V. Phone/Fax

Practice location:
  • Phone: 714-748-6210
  • Fax:
Mailing address:
  • Phone: 949-492-2698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC29703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: