Healthcare Provider Details

I. General information

NPI: 1558839746
Provider Name (Legal Business Name): KRISTINA RUSSELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 EAGLE CREST DR NE STE 100
GRAND RAPIDS MI
49525-7005
US

IV. Provider business mailing address

2539 CREEK BLUFF PL NW
GRAND RAPIDS MI
49504-2357
US

V. Phone/Fax

Practice location:
  • Phone: 616-409-4393
  • Fax:
Mailing address:
  • Phone: 616-260-3634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401019274
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: