Individual
DR. MICHELE C RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
3313 N HILLIARD ST, FRESNO, CA 93726-5854
(559) 227-4810
(559) 227-4167
Mailing address
PO BOX 357, AHWAHNEE, CA 93601-0357
(559) 908-1516
(559) 642-6990
Taxonomy
Speciality
Code
Description
License number
State
103G00000X
Clinical Neuropsychologist
Primary
PSY20822
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OPL208220
MEDICARE PTAN
CA
01
—
PSY20822
CA LICENSE NUMBER
—
01
—
PSY208220
MEDICAID PROVIDER NUMBER
CA
Enumeration date
07/19/2006
Last updated
06/26/2008
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