| Doctor Name: | DR. KEITH DUNCAN RUSSELL |
| NPI Number: | 1023239662 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH.D.,L.M.S.W. |
| License Number: | 6801012479 |
| Business Practice Address: | 20816 E 11 Mile Rd Suite 113 Saint Clair Shores, MI - 480811565 |
| Business Phone Number: | 5864470130 |
| Business Fax Number: | |
| Mailing Address: | 20816 E 11 Mile Rd Ste 113, SAINT CLAIR SHORES |
| State: | MI |
| Postal Code: | 480811534 |
| Phone Number: | 5864470130 |
| Fax Number: | |
| NPI Enumeration Date: | 05/01/2007 |
| NPI Last Update Date: | 03/05/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 6801012479 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |