Provider Demographics
NPI:1699134262
Name:RUSS, RANDALL
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:RUSS
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 1:32990 BOWIE STREET
Mailing Address - Street 2:
Mailing Address - City:WHITE CASTLE
Mailing Address - State:LA
Mailing Address - Zip Code:70788
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32990 BOWIE STREET
Practice Address - Street 2:
Practice Address - City:WHITE CASTLE
Practice Address - State:LA
Practice Address - Zip Code:70788
Practice Address - Country:US
Practice Address - Phone:225-716-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health