1346983533 NPI number — RUSSEL RAY WHITEHALL LMHC

Table of content: RUSSEL RAY WHITEHALL LMHC (NPI 1346983533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346983533 NPI number — RUSSEL RAY WHITEHALL LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITEHALL
Provider First Name:
RUSSEL
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346983533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601422
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92160-1422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-840-6956
Provider Business Mailing Address Fax Number:
619-383-6701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5109 NE 82ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98662-6199
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-840-6956
Provider Business Practice Location Address Fax Number:
619-383-6701
Provider Enumeration Date:
04/15/2022

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: 101YM0800X , with the licence number:  LH61493637 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0755984 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91-0755984 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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