Provider Demographics
NPI:1609690650
Name:SASS, RUSSELL (PPS, JD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:SASS
Suffix:
Gender:M
Credentials:PPS, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34217 AUCKLAND PL
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-2326
Mailing Address - Country:US
Mailing Address - Phone:510-972-8008
Mailing Address - Fax:
Practice Address - Street 1:4620 MATTOS DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-6738
Practice Address - Country:US
Practice Address - Phone:510-797-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240100064101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool