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NPI Code Detail

MEDICARE: DR. RUSSELL GLENDON COULTER-KERN PH.D.

MEDICARE: DR. RUSSELL GLENDON COULTER-KERN PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologist20040896AIN

General Provider Information

NPI Number : 1255312187
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. RUSSELL GLENDON COULTER-KERN PH.D.
Provider Business Mailing Address
First Line : 1604 W HECKATHORN DR
Second Line :
City : NORTH MANCHESTER
State : IN
Zip : 46962-2217
Country : US
Telephone Number : 260-982-9383
Fax Number :
Provider Business Practice Location Address
First Line : 1118 N WAYNE ST
Second Line :
City : NORTH MANCHESTER
State : IN
Zip : 46962-1001
Country : US
Telephone Number : 260-982-5349
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/08/2005
Last Update Date : 07/08/2007

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