MEDICARE: RUSSELL H. REEVES 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
1	103TC0700X	Clinical Psychologist	L743242	MI

General Provider Information

NPI Number	:	1629011051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL H. REEVES PHD

Provider Business Mailing Address
First Line	:	1640 AXTELL DR
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-4431
Country	:	US
Telephone Number	:	248-649-7191
Fax Number	:	248-649-5445

Provider Business Practice Location Address
First Line	:	1640 AXTELL DR
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-4431
Country	:	US
Telephone Number	:	248-649-7191
Fax Number	:	248-649-5445

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	07/08/2007

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