Provider Demographics
NPI:1962546580
Name:RUSSELL, HEATHER FLYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:FLYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SHRINERS HOSPITAL FOR CHILDREN PHILADELPHIA
Mailing Address - Street 2:LOCKBOX #7642 - PO BOX 8500
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0001
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-218-8113
Practice Address - Street 1:3551 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4160
Practice Address - Country:US
Practice Address - Phone:215-430-4022
Practice Address - Fax:215-430-4079
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015004103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist