Provider Demographics
NPI:1588702773
Name:RUSSELL, TERENCE P (MA)
Entity type:Individual
Prefix:MR
First Name:TERENCE
Middle Name:P
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 WATER ST STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-4126
Mailing Address - Country:US
Mailing Address - Phone:831-462-8260
Mailing Address - Fax:831-462-8262
Practice Address - Street 1:550 WATER ST STE A
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4126
Practice Address - Country:US
Practice Address - Phone:831-462-8260
Practice Address - Fax:831-462-8262
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU610231HA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHA1037OtherHEARING AID DISPENSER
CAAU610OtherCALIFORNIA AUDIOLOGY LICE