Healthcare Provider Details

I. General information

NPI: 1083084834
Provider Name (Legal Business Name): ALEXIS RAY RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14430 CARIBBEAN DR
GONZALES LA
70737-7086
US

IV. Provider business mailing address

14430 CARIBBEAN DR
GONZALES LA
70737-7086
US

V. Phone/Fax

Practice location:
  • Phone: 225-993-6861
  • Fax:
Mailing address:
  • Phone: 225-993-6861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: