Basic Information
| Provider Information | |||||||||
| NPI: | 1487203485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | E.B. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1502 TAUB LOOP | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301608 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1504 BEN TAUB LOOP | ||||||||
| Address2: | |||||||||
| City: | HOUTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138732000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2019 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 38283 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.