Healthcare Provider Details

I. General information

NPI: 1942220967
Provider Name (Legal Business Name): RUSSELL G HOFFMANN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8888 LADUE RD #120
SAINT LOUIS MO
63124-2056
US

IV. Provider business mailing address

8888 LADUE RD #120
SAINT LOUIS MO
63124-2056
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6069
  • Fax: 314-726-6069
Mailing address:
  • Phone: 314-454-6069
  • Fax: 314-726-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY01819
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: