Healthcare Provider Details

I. General information

NPI: 1679290274
Provider Name (Legal Business Name): KELLI RUSSELL M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 SHADYTREE LN
ENCINITAS CA
92024-3121
US

IV. Provider business mailing address

270 N EL CAMINO REAL # 112F
ENCINITAS CA
92024-2874
US

V. Phone/Fax

Practice location:
  • Phone: 858-733-1617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: