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General NPI Number Information
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NPI Number | 1639579675
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Entity Type | Individual
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Provider Name | MR. THOMAS RUSSELL II
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Gender | Male
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Dates
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Enumeration Date | 08/27/2014
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Last Update Date | 08/27/2014
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Provider Practice Location Address
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Address Line | 3780 KILROY AIRPORT WAY
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City | LONG BEACH
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State | CA
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Zip | 90806-2457
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Country | US
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Telephone | 562-424-6015
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Fax | 562-988-6897
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Provider Business Mailing Address
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Address Line | 15281 DEERWOOD LN
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City | FONTANA
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State | CA
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Zip | 92336-0774
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Country | US
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Telephone | 909-899-6095
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Fax | 909-899-6095
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 94020370
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 94020370
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 101067938
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 76881
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License Number State | CA
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