Healthcare Provider Details

I. General information

NPI: 1629252192
Provider Name (Legal Business Name): RUSSELL C. FREELAND, EDD, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 OFFICERS ROW
VANCOUVER WA
98661-3836
US

IV. Provider business mailing address

650 OFFICERS ROW
VANCOUVER WA
98661-3836
US

V. Phone/Fax

Practice location:
  • Phone: 360-695-3012
  • Fax: 360-574-6979
Mailing address:
  • Phone: 360-695-3012
  • Fax: 360-574-6979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number573
License Number StateWA

VIII. Authorized Official

Name: DR. RUSSELL C FREELAND
Title or Position: PRESIDENT
Credential: PHD
Phone: 360-695-3012