Healthcare Provider Details

I. General information

NPI: 1659524361
Provider Name (Legal Business Name): LORI RUSS-EISENSCHENK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2008
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 SW 87TH DR SUITE A
GAINESVILLE FL
32608-9313
US

IV. Provider business mailing address

2653 SW 87TH DR SUITE A
GAINESVILLE FL
32608-9313
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-0020
  • Fax: 352-331-0022
Mailing address:
  • Phone: 352-331-0020
  • Fax: 352-331-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY5935
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: