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1639579675 NPI number — MR. THOMAS RUSSELL II

NPI Number: 1639579675
Health Care Provider/Practitioner: MR. THOMAS RUSSELL II

Information about “1639579675” NPI (MR. THOMAS RUSSELL II) exists in 1639579675 in HTML format HTML  |  1639579675 in plain Text format TXT  |  1639579675 in PDF (Portable Document Format) PDF  |  1639579675 in an XML format XML  formats.

NPI Number : 1639579675 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1639579675",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "RUSSELL",
    "FirstName": "THOMAS",
    "MiddleName": null,
    "NamePrefix": "MR.",
    "NameSuffix": "II",
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "15281 DEERWOOD LN",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "FONTANA",
    "MailingAddressStateName": "CA",
    "MailingAddressPostalCode": "92336-0774",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "909-899-6095",
    "MailingAddressFaxNumber": "909-899-6095",
    "FirstLinePracticeLocationAddress": "3780 KILROY AIRPORT WAY",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "LONG BEACH",
    "PracticeLocationAddressStateName": "CA",
    "PracticeLocationAddressPostalCode": "90806-2457",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "562-424-6015",
    "PracticeLocationAddressFaxNumber": "562-988-6897",
    "EnumerationDate": "08/27/2014",
    "LastUpdateDate": "08/27/2014",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "101YA0400X",
          "TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
          "LicenseNumber": "94020370",
          "LicenseNumberStateCode": "CA",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "101YM0800X",
          "TaxonomyName": "Mental Health Counselor",
          "LicenseNumber": "94020370",
          "LicenseNumberStateCode": "CA",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "103TS0200X",
          "TaxonomyName": "School Psychologist",
          "LicenseNumber": "101067938",
          "LicenseNumberStateCode": "CA",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "106H00000X",
          "TaxonomyName": "Marriage & Family Therapist",
          "LicenseNumber": "76881",
          "LicenseNumberStateCode": "CA",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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