Provider Demographics
NPI:1730627209
Name:RUSSUM, ANDREA (MS)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:
Last Name:RUSSUM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:KEEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:417 RIVERMONT DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5930
Mailing Address - Country:US
Mailing Address - Phone:931-249-4723
Mailing Address - Fax:
Practice Address - Street 1:1820 MEMORIAL CIR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4539
Practice Address - Country:US
Practice Address - Phone:931-436-2126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health