Basic Information
| Provider Information | |||||||||
| NPI: | 1992360200 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSS | ||||||||
| FirstName: | LUCIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4585 SW 185TH AVE | ||||||||
| Address2: | |||||||||
| City: | ALOHA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970781557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0361959280 | ||||||||
| FaxNumber: | 5038482072 | ||||||||
| Practice Location | |||||||||
| Address1: | 4585 SW 185TH AVE | ||||||||
| Address2: | |||||||||
| City: | ALOHA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970781557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0361959280 | ||||||||
| FaxNumber: | 5038482072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2019 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | SC60768028 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.