Provider Demographics
NPI:1386244648
Name:RUSSELL, MATTHEW B
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
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 1:4125 TEMESCAL ST STE G
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-7558
Mailing Address - Country:US
Mailing Address - Phone:916-619-7744
Mailing Address - Fax:
Practice Address - Street 1:4125 TEMESCAL ST STE G
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7558
Practice Address - Country:US
Practice Address - Phone:916-619-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT122031106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist