Basic Information
| Provider Information | |||||||||
| NPI: | 1851923858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | CHARMAIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11263 OLD 63 S APT 59 | ||||||||
| Address2: | |||||||||
| City: | LUCEDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394526656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015089131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 57 INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | LUCEDALE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394526583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019474274 | ||||||||
| FaxNumber: | 6019474275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2020 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000181214 | 05 | MS | MEDICAID |