Healthcare Provider Details

I. General information

NPI: 1053376517
Provider Name (Legal Business Name): RUSSELL RADENHAUSEN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 SCOTT ST
COVINGTON KY
41011-2418
US

IV. Provider business mailing address

502 FARRELL DR
COVINGTON KY
41011-3717
US

V. Phone/Fax

Practice location:
  • Phone: 859-431-2225
  • Fax: 859-431-2588
Mailing address:
  • Phone: 859-331-3292
  • Fax: 859-578-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number531
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: