Provider Demographics
NPI:1215143193
Name:STAMBAUGH, RUSSELL J JR (PHD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:J
Last Name:STAMBAUGH
Suffix:JR
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E WASHINGTON ST STE 400A2
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-2017
Mailing Address - Country:US
Mailing Address - Phone:734-769-6305
Mailing Address - Fax:734-996-4964
Practice Address - Street 1:202 E WASHINGTON ST STE 400A2
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2017
Practice Address - Country:US
Practice Address - Phone:734-769-6305
Practice Address - Fax:734-996-4964
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2025-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005967103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical