Provider Demographics
NPI:1548955800
Name:RUSSELL, MEGAN MEKENZIE (M ED, T-LPC)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:MEKENZIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:M ED, T-LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 FOOTHILLS MALL DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-5515
Mailing Address - Country:US
Mailing Address - Phone:865-748-8556
Mailing Address - Fax:
Practice Address - Street 1:211 FOOTHILLS MALL DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-5515
Practice Address - Country:US
Practice Address - Phone:865-748-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health