Provider Demographics
NPI:1902112816
Name:RUSSELL, RONNIE JEROME I (M DIV)
Entity Type:Individual
Prefix:MR
First Name:RONNIE
Middle Name:JEROME
Last Name:RUSSELL
Suffix:I
Gender:M
Credentials:M DIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 VENTURE CIR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-1604
Mailing Address - Country:US
Mailing Address - Phone:615-460-4288
Mailing Address - Fax:615-460-4202
Practice Address - Street 1:717 HART LN
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37216-2007
Practice Address - Country:US
Practice Address - Phone:615-227-7688
Practice Address - Fax:615-460-4202
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor