Healthcare Provider Details

I. General information

NPI: 1144690348
Provider Name (Legal Business Name): CARL LEE RUSSELL M.A. DMIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 MOON ST NE
ALBUQUERQUE NM
87112-2709
US

IV. Provider business mailing address

2030 MOON ST NE
ALBUQUERQUE NM
87112-2709
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-7620
  • Fax:
Mailing address:
  • Phone: 505-298-7620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberT-0177631
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: