Healthcare Provider Details

I. General information

NPI: 1801943469
Provider Name (Legal Business Name): WILLIAM F. RUSSELL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 VINE ST SUITE 300
PHILADELPHIA PA
19107-1111
US

IV. Provider business mailing address

1241 VINE ST
PHILADELPHIA PA
19107-1111
US

V. Phone/Fax

Practice location:
  • Phone: 215-405-2100
  • Fax:
Mailing address:
  • Phone: 215-405-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPS 006981 L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: