=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841745296
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSS NORDMEYER MFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2016
-----------------------------------------------------
Last Update Date | 02/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 MONTGOMERY ST SUITE 400
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94104-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-225-2755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 SHOTWELL ST #3
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94103-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-225-2755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 93284
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------