Basic Information
| Provider Information | |||||||||
| NPI: | 1396377917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | RENAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11662 S OAKMOND RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840095049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3853949616 | ||||||||
| FaxNumber: | 8014831610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1208 E 3300 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841062522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014831600 | ||||||||
| FaxNumber: | 8014831610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2020 | ||||||||
| LastUpdateDate: | 02/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 10322316-6004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.