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General NPI Number Information
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NPI Number | 1083014773
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Entity Type | Organization
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Legal Business Name | BENJAMINRUSSACK
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Dates
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Enumeration Date | 08/29/2014
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Last Update Date | 08/29/2014
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Provider Practice Location Address
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Address Line | 20 SHELLEY DR APT 6
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City | MILL VALLEY
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State | CA
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Zip | 94941-1562
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Country | US
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Telephone | 415-497-1908
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Fax |
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Provider Business Mailing Address
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Address Line | 20 SHELLEY DR APT 6
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City | MILL VALLEY
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State | CA
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Zip | 94941-1562
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Country | US
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Telephone | 415-497-1908
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Fax |
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Authorized Official
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Title or Position | MFT
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Name | MR. BENJAMIN D RUSSACK
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Credential |
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Telephone | 415-497-1908
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 78602
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License Number State | CA
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