Healthcare Provider Details

I. General information

NPI: 1699887901
Provider Name (Legal Business Name): RUSSELL ARTHUR SURVEYER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 CEDAR ST
WORCESTER MA
01609-2134
US

IV. Provider business mailing address

1620 WACHUSETT ST
JEFFERSON MA
01522-1302
US

V. Phone/Fax

Practice location:
  • Phone: 508-868-5609
  • Fax: 508-870-9991
Mailing address:
  • Phone: 508-868-5609
  • Fax: 508-870-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMALMHC 2066
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberMALMHC 2066
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMHC00455
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: