Healthcare Provider Details

I. General information

NPI: 1285640128
Provider Name (Legal Business Name): MICHAEL RUSSELL M.A., D.MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 ROCK PRAIRIE RD SUITE B
COLLEGE STATION TX
77845-8777
US

IV. Provider business mailing address

207 ROCK PRAIRIE RD SUITE B
COLLEGE STATION TX
77845-8777
US

V. Phone/Fax

Practice location:
  • Phone: 979-693-3393
  • Fax: 979-694-7337
Mailing address:
  • Phone: 979-693-3393
  • Fax: 979-694-7337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9957
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: