Basic Information
| Provider Information | |||||||||
| NPI: | 1871887372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4413 CORUNNA RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106301152 | ||||||||
| FaxNumber: | 8106309107 | ||||||||
| Practice Location | |||||||||
| Address1: | 4413 CORUNNA RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106301152 | ||||||||
| FaxNumber: | 8106309107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2011 | ||||||||
| LastUpdateDate: | 12/17/2013 | ||||||||
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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 | 6401012403 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.