Basic Information
| Provider Information | |||||||||
| NPI: | 1275986333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORRIS | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1923 SULPHUR SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378135654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233179344 | ||||||||
| FaxNumber: | 4237142355 | ||||||||
| Practice Location | |||||||||
| Address1: | 4330 MAYNARDVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | MAYNARDVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659923849 | ||||||||
| FaxNumber: | 8659925166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2016 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.