Healthcare Provider Details

I. General information

NPI: 1790607240
Provider Name (Legal Business Name): MS. AUDRIA ANN-MARIE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 N TERRACE AVE APT 2B
MOUNT VERNON NY
10552-2754
US

IV. Provider business mailing address

670 N TERRACE AVE APT 2B
MOUNT VERNON NY
10552-2754
US

V. Phone/Fax

Practice location:
  • Phone: 914-918-9384
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0862901
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number44SL05941700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: