Healthcare Provider Details

I. General information

NPI: 1720498785
Provider Name (Legal Business Name): CORY ANTHONY RUSSELL LPCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CORY ANTHONY RUSSELL LPC

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

438 BARNWELL RD
ALLENDALE SC
29810
US

IV. Provider business mailing address

1050 RIBAUT RD
BEAUFORT SC
29902-5400
US

V. Phone/Fax

Practice location:
  • Phone: 803-584-4636
  • Fax:
Mailing address:
  • Phone: 843-524-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6131
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: