MEDICARE: TONY RUSSELL MARRIAGE AND FAMILY THERAPY INC

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	106H00000X	Marriage & Family Therapist	MFC42048	CA

General Provider Information

NPI Number	:	1871953992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TONY RUSSELL MARRIAGE AND FAMILY THERAPY INC

Provider Business Mailing Address
First Line	:	PO BOX 163420
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-9420
Country	:	US
Telephone Number	:	916-443-1931
Fax Number	:	916-443-1132

Provider Business Practice Location Address
First Line	:	2621 CAPITOL AVE
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-5920
Country	:	US
Telephone Number	:	916-443-1931
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ANTHONY DUKE RUSSELL
Credential	:	LMFT
Telephone Number	:	916-443-1931

Provider Enumeration Date	:	03/02/2016
Last Update Date	:	03/02/2016

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