Healthcare Provider Details

I. General information

NPI: 1518622984
Provider Name (Legal Business Name): RICHELE RENE RUSSOM LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2021
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-6731
US

IV. Provider business mailing address

1501 SAN PEDRO DR NE
ALBUQUERQUE NM
87110-6731
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-4530
  • Fax: 505-823-4538
Mailing address:
  • Phone: 505-823-4530
  • Fax: 505-823-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0215911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: