Basic Information
| Provider Information | |||||||||
| NPI: | 1437802527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | CHARLES CLARK | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 692 RAVENNA CIR | ||||||||
| Address2: | |||||||||
| City: | REYNOLDSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430681625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3852080095 | ||||||||
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| Practice Location | |||||||||
| Address1: | 187 W SCHROCK RD | ||||||||
| Address2: | |||||||||
| City: | WESTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430812890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143557500 | ||||||||
| FaxNumber: | 6143557533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2022 | ||||||||
| LastUpdateDate: | 03/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 08253 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.