Healthcare Provider Details

I. General information

NPI: 1942770409
Provider Name (Legal Business Name): KELLY LEONORA RUSSELL LMFT, CDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 12TH AVE S
SEATTLE WA
98144-2007
US

IV. Provider business mailing address

611 12TH AVE S
SEATTLE WA
98144-2007
US

V. Phone/Fax

Practice location:
  • Phone: 206-324-9360
  • Fax:
Mailing address:
  • Phone: 206-324-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60846150
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLF60294042
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: