Healthcare Provider Details

I. General information

NPI: 1467190777
Provider Name (Legal Business Name): THOMAS MICHAEL RUSSELL JR. BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: THOMAS MICHAEL RUSSELL JR. BA

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5966 SCOTTSVILLE RD
BOWLING GREEN KY
42104-0387
US

IV. Provider business mailing address

211 WESTBROOK RD
ALVATON KY
42122-8682
US

V. Phone/Fax

Practice location:
  • Phone: 270-904-5104
  • Fax:
Mailing address:
  • Phone: 502-553-5746
  • 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: