MEDICARE: MS. MYLINDA ORENE RUSSELL SR. PSYCH. EXAMINER

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	101YP2500X	Professional Counselor	SLPE 1414	TN

General Provider Information

NPI Number	:	1831184498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MYLINDA ORENE RUSSELL SR. PSYCH. EXAMINER

Provider Business Mailing Address
First Line	:	1413 S HOME ST
Second Line	:	P.O. BOX 0057
City	:	UNION CITY
State	:	TN
Zip	:	38261-5748
Country	:	US
Telephone Number	:	731-885-0201
Fax Number	:	731-884-2998

Provider Business Practice Location Address
First Line	:	1413 S HOME ST
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-5748
Country	:	US
Telephone Number	:	731-885-0201
Fax Number	:	731-884-2998

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	07/08/2007

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