Provider Demographics
NPI:1487958963
Name:RUSSELL, VALERIE L
Entity type:Individual
Prefix:DR
First Name:VALERIE
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BUCKTHORN DR
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92823-7003
Mailing Address - Country:US
Mailing Address - Phone:714-309-1007
Mailing Address - Fax:
Practice Address - Street 1:130 BUCKTHORN DR
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92823-7003
Practice Address - Country:US
Practice Address - Phone:714-309-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-27
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical