Healthcare Provider Details

I. General information

NPI: 1578007803
Provider Name (Legal Business Name): SANDTRICE RUSSELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7117 WALTON HL
FAIRBURN GA
30213-7112
US

IV. Provider business mailing address

203 VINE ST
LAGRANGE GA
30241-3346
US

V. Phone/Fax

Practice location:
  • Phone: 404-924-5560
  • Fax:
Mailing address:
  • Phone: 404-924-5560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC009310
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC009310
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009310
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: