Provider Demographics
NPI:1538542097
Name:RUSSELL, CRYSTAL M (LPCC, CDCA)
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPCC, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 ANDOVER RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1911
Mailing Address - Country:US
Mailing Address - Phone:419-528-5994
Mailing Address - Fax:
Practice Address - Street 1:1338 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1828
Practice Address - Country:US
Practice Address - Phone:419-528-5994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC15000630101Y00000X
OHCDCA162724101YA0400X
OHC1500630101YM0800X
OHE.2102678101YM0800X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program