Healthcare Provider Details

I. General information

NPI: 1588984603
Provider Name (Legal Business Name): NICHOLAS AARON RUSSELL LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 CUBA AVE STE 1
ALAMOGORDO NM
88310-5646
US

IV. Provider business mailing address

3122 SUMMER AVE
ALAMOGORDO NM
88310-4062
US

V. Phone/Fax

Practice location:
  • Phone: 575-404-1593
  • Fax: 575-404-1593
Mailing address:
  • Phone: 575-404-1593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberE0700288S
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE0700288S
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0206781
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: