Healthcare Provider Details

I. General information

NPI: 1841999117
Provider Name (Legal Business Name): MR. RUSSELL CURTIS SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 02/27/2023
Certification Date: 02/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3745 CUERVO CT NW
ALBUQUERQUE NM
87107-2466
US

IV. Provider business mailing address

3745 CUERVO CT NW
ALBUQUERQUE NM
87107-2466
US

V. Phone/Fax

Practice location:
  • Phone: 973-454-5869
  • Fax:
Mailing address:
  • Phone: 973-454-5869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2022-0885
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: