Healthcare Provider Details

I. General information

NPI: 1942510573
Provider Name (Legal Business Name): TINA DENISE RUSSELL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2010
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 S MISSISSIPPI AVE
ATOKA OK
74525-2500
US

IV. Provider business mailing address

610 E 24TH ST
TISHOMINGO OK
73460-3245
US

V. Phone/Fax

Practice location:
  • Phone: 580-889-4746
  • Fax: 580-889-4735
Mailing address:
  • Phone: 580-371-2343
  • Fax: 580-371-3614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number92437
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC05924
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61487142
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: