Provider Demographics
NPI:1154722999
Name:RUSSELL, EILEEN M (PHD)
Entity type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 5TH AVE
Mailing Address - Street 2:STE. 1103
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6601
Mailing Address - Country:US
Mailing Address - Phone:212-714-5003
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE
Practice Address - Street 2:STE. 1103
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6601
Practice Address - Country:US
Practice Address - Phone:212-714-5003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SJ00459700103TC0700X
NY014384103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical