Healthcare Provider Details

I. General information

NPI: 1679818074
Provider Name (Legal Business Name): LAURA J RUSSELL LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA J MACKENZIE LPC

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 MILLARD FARMER IND BLVD SUITE B1
NEWNAN GA
30263-5821
US

IV. Provider business mailing address

PO BOX 73972
NEWNAN GA
30271-3972
US

V. Phone/Fax

Practice location:
  • Phone: 678-435-9949
  • Fax:
Mailing address:
  • Phone: 678-435-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number008111
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401012348
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: