MEDICARE: MR. RUSSELL KENT OWENS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	004996	GA

General Provider Information

NPI Number	:	1811922503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSSELL KENT OWENS LPC

Provider Business Mailing Address
First Line	:	4661 IVY PATCH DR
Second Line	:
City	:	FORTSON
State	:	GA
Zip	:	31808-6897
Country	:	US
Telephone Number	:	706-315-5474
Fax Number	:

Provider Business Practice Location Address
First Line	:	5638 WARM SPRINGS RD
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31909-2408
Country	:	US
Telephone Number	:	706-221-9210
Fax Number	:	706-221-5427

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	12/12/2014

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