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General NPI Number Information
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NPI Number | 1376665992
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Entity Type | Organization
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Legal Business Name | ANGELA RUSSELL
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 06/25/2008
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Provider Practice Location Address
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Address Line | 1300 MERCANTILE LN SUITE 139-J
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City | LARGO
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State | MD
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Zip | 20774-5327
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Country | US
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Telephone | 301-574-5976
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Fax | 301-574-5986
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Provider Business Mailing Address
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Address Line | 16306 BROOKTRAIL CT
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City | UPPER MARLBORO
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State | MD
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Zip | 20772-3272
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Country | US
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Telephone | 301-574-5976
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Fax | 301-574-5986
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. ANGELA L RUSSELL
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Credential | LCPC
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Telephone | 301-574-5976
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | LC1591
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License Number State | MD
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