Healthcare Provider Details

I. General information

NPI: 1861725160
Provider Name (Legal Business Name): RUSSELL A HARDESTY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2009
Last Update Date: 09/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 COUNTY ROAD 281
AUXVASSE MO
65231-1128
US

IV. Provider business mailing address

807 COUNTY ROAD 281
AUXVASSE MO
65231-1128
US

V. Phone/Fax

Practice location:
  • Phone: 573-387-4528
  • Fax: 573-387-4849
Mailing address:
  • Phone: 573-387-4528
  • Fax: 573-387-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001224
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: