Provider Demographics
NPI:1124430731
Name:ROBERTSON, RUSSELL
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 N HILL FIELD RD
Mailing Address - Street 2:STE 103
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4781
Mailing Address - Country:US
Mailing Address - Phone:801-525-4645
Mailing Address - Fax:
Practice Address - Street 1:2317 N HILL FIELD RD
Practice Address - Street 2:STE 103
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4781
Practice Address - Country:US
Practice Address - Phone:801-525-4645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-30
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical