Provider Demographics
NPI:1285171892
Name:RUSSELL, RANDALL SHANE
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:SHANE
Last Name:RUSSELL
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 1:239 WEST DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-5149
Mailing Address - Country:US
Mailing Address - Phone:662-816-4365
Mailing Address - Fax:
Practice Address - Street 1:158 MCGEHEE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-5012
Practice Address - Country:US
Practice Address - Phone:225-272-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-21
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health