Healthcare Provider Details

I. General information

NPI: 1154767267
Provider Name (Legal Business Name): MARK STEPHEN RUSSELL JR. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1448 NW MARKET ST STE 210
SEATTLE WA
98107-3743
US

IV. Provider business mailing address

1448 NW MARKET ST STE 210
SEATTLE WA
98107-3743
US

V. Phone/Fax

Practice location:
  • Phone: 206-910-9476
  • Fax:
Mailing address:
  • Phone: 206-910-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number76034
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number61663881
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: