Basic Information
| Provider Information | |||||||||
| NPI: | 1003394180 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 KENMORE DR | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449062244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197350879 | ||||||||
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| Practice Location | |||||||||
| Address1: | 151 MARION AVE | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 449032223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197749969 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2018 | ||||||||
| LastUpdateDate: | 08/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.007679 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.