Healthcare Provider Details

I. General information

NPI: 1134171945
Provider Name (Legal Business Name): TERESA MARIE RUSSELL PSYD, LCPC, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10299 REINDEER PL
NEW MARKET MD
21774-6818
US

IV. Provider business mailing address

10299 REINDEER PL
NEW MARKET MD
21774-6818
US

V. Phone/Fax

Practice location:
  • Phone: 240-575-1206
  • Fax:
Mailing address:
  • Phone: 240-575-1206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCP000009
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC5788
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberTPMC80
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCP000009
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMHC863
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: