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General NPI Number Information
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NPI Number | 1326040148
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Entity Type | Individual
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Provider Name | GERALD LEE RUSSELL PHD
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Gender | Male
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 713 6TH ST
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City | LAS VEGAS
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State | NM
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Zip | 87701-4359
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Country | US
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Telephone | 505-429-4679
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Fax | 505-425-3370
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Provider Business Mailing Address
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Address Line | PO BOX 1705
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City | LAS VEGAS
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State | NM
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Zip | 87701-1705
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Country | US
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Telephone | 505-454-2202
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Fax | 505-454-2211
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 761
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License Number State | NM
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