Healthcare Provider Details

I. General information

NPI: 1700177391
Provider Name (Legal Business Name): RUSSELL D PELLA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7146 S BRADEN AVE STE 500
TULSA OK
74136-6376
US

IV. Provider business mailing address

5383 S IRVINGTON AVE
TULSA OK
74135-7524
US

V. Phone/Fax

Practice location:
  • Phone: 918-986-7036
  • Fax: 833-317-4151
Mailing address:
  • Phone: 918-986-7036
  • Fax: 833-317-4151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1248
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number34782
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: