Provider Demographics
NPI:1487485322
Name:RUSSELL, CHRISTOPHER PAUL (MS ED, TVI)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:PAUL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MS ED, TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 43RD AVE APT DW
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2766
Mailing Address - Country:US
Mailing Address - Phone:650-722-2319
Mailing Address - Fax:
Practice Address - Street 1:649 39TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-3101
Practice Address - Country:US
Practice Address - Phone:718-851-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1412542174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist