Healthcare Provider Details

I. General information

NPI: 1770422230
Provider Name (Legal Business Name): TERRENCE RENARD RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13706 HOTOMTOT DR
LARGO MD
20774-7156
US

IV. Provider business mailing address

13706 HOTOMTOT DR
LARGO MD
20774-7156
US

V. Phone/Fax

Practice location:
  • Phone: 216-438-3349
  • Fax:
Mailing address:
  • Phone: 216-438-3349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMD-10275319231
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: