Healthcare Provider Details

I. General information

NPI: 1376877407
Provider Name (Legal Business Name): ILLYSSA MARIE RUSSELL LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 AMERICAN GREETING CARD RD
CORBIN KY
40701-4811
US

IV. Provider business mailing address

PO BOX 568
CORBIN KY
40702-0568
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-7010
  • Fax:
Mailing address:
  • Phone: 606-528-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number167704
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: