Provider Demographics
NPI:1215148671
Name:MEYERHOFER, RUSSELL J (PHD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:MEYERHOFER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2614
Mailing Address - Country:US
Mailing Address - Phone:719-569-2738
Mailing Address - Fax:
Practice Address - Street 1:1919 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2614
Practice Address - Country:US
Practice Address - Phone:719-569-2738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2024-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004796103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical