Healthcare Provider Details

I. General information

NPI: 1023372695
Provider Name (Legal Business Name): THOMAS J RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 FRONT ST SUITE 490
WORCESTER MA
01608-1733
US

IV. Provider business mailing address

519 E RIVER ST #18
ORANGE MA
01364-2106
US

V. Phone/Fax

Practice location:
  • Phone: 508-799-2934
  • Fax:
Mailing address:
  • Phone: 978-544-1897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: