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General NPI Number Information
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NPI Number | 1306032875
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Entity Type | Individual
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Provider Name | MELONIA SUE RUSSELL LMFT
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Gender | Female
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Dates
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Enumeration Date | 09/19/2007
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Last Update Date | 09/19/2007
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Provider Practice Location Address
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Address Line | 1400 W INDIANA AVE
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City | ELKHART
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State | IN
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Zip | 46516-2164
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Country | US
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Telephone | 546-276-3775
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 462
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City | BREMEN
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State | IN
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Zip | 46506-0462
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Country | US
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Telephone | 574-276-3775
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 35001623A
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License Number State | IN
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