1245437417 NPI number — MR. RUSSELL BENSON MCCLOUD MSW, LCSW

Table of content: MR. RUSSELL BENSON MCCLOUD MSW, LCSW (NPI 1245437417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245437417 NPI number — MR. RUSSELL BENSON MCCLOUD MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLOUD
Provider First Name:
RUSSELL
Provider Middle Name:
BENSON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCLOUD
Provider Other First Name:
RUSSELL
Provider Other Middle Name:
BENSON
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1245437417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20204 LAKERIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERRIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92570-8421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-776-9184
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5225 CANYON CREST DR
Provider Second Line Business Practice Location Address:
BLDG. 400, SUITE 411
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92507-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-248-4042
Provider Business Practice Location Address Fax Number:
951-248-4049
Provider Enumeration Date:
06/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCS 10485 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com