Provider Demographics
NPI:1548333180
Name:RUSSELL, MARY JANELLE (LPC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANELLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4101 N LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-7904
Mailing Address - Country:US
Mailing Address - Phone:580-920-2016
Mailing Address - Fax:580-924-6775
Practice Address - Street 1:1105 LYNNWOOD ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2919
Practice Address - Country:US
Practice Address - Phone:580-931-3441
Practice Address - Fax:580-924-6775
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2697101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health