Individual
GERALD LEE RUSSELL
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
PHD
Contact information
Practice address
713 6TH ST, LAS VEGAS, NM 87701-4359
(505) 429-4679
(505) 425-3370
Mailing address
PO BOX 1705, LAS VEGAS, NM 87701-1705
(505) 454-2202
(505) 454-2211
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
761
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
76705
—
NM
Enumeration date
08/11/2005
Last updated
07/08/2007
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