Healthcare Provider Details

I. General information

NPI: 1366642761
Provider Name (Legal Business Name): STANLEY WAYNE RUSSELL LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S SHORE DR UNIT 224
BATTLE CREEK MI
49014-5440
US

IV. Provider business mailing address

601 S SHORE DR UNIT 224
BATTLE CREEK MI
49014-5440
US

V. Phone/Fax

Practice location:
  • Phone: 269-979-8119
  • Fax:
Mailing address:
  • Phone: 269-979-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401010247
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401010247
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number6401010247
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010247
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: