Healthcare Provider Details

I. General information

NPI: 1801946405
Provider Name (Legal Business Name): MARY KATHERINE RUSSELL LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 ARLINGTON AVE SUITE B
RIVERSIDE CA
92504-1955
US

IV. Provider business mailing address

5790 MAGNOLIA AVE SUITE 202
RIVERSIDE CA
92506-1874
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-4964
  • Fax: 951-352-4965
Mailing address:
  • Phone: 909-855-0302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC 36287
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: