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NPI Code Detail

MEDICARE: DR. PENELOPE LOUISE RUSSELL PHD

MEDICARE: DR. PENELOPE LOUISE RUSSELL PHD
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
1103TF0200XForensic Psychologist

General Provider Information

NPI Number : 1508061516
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. PENELOPE LOUISE RUSSELL PHD
Provider Business Mailing Address
First Line : 3373 DWIGHT WAY
Second Line :
City : BERKELEY
State : CA
Zip : 94704-2522
Country : US
Telephone Number : 510-981-1037
Fax Number :
Provider Business Practice Location Address
First Line : 5325 BRODER BLVD
Second Line :
City : DUBLIN
State : CA
Zip : 94568-3309
Country : US
Telephone Number : 925-551-6737
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/19/2007
Last Update Date : 07/08/2007

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