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General NPI Number Information
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NPI Number | 1376727446
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Entity Type | Individual
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Provider Name | THOMAS A. RUSSELL M.A., M.ED., PCCS
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Gender | Male
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Dates
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Enumeration Date | 12/24/2007
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Last Update Date | 12/24/2007
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Provider Practice Location Address
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Address Line | 788 LEXINGTON AVENUE HERITAGE CHRISTIAN COUNSELING MINISTRIES
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City | MANSFIELD
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State | OH
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Zip | 44907
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Country | US
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Telephone | 419-756-2828
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Fax |
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Provider Business Mailing Address
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Address Line | 788 LEXINGTON AVENUE HERITAGE CHRISTIAN COUNSELING MINISTRIES
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City | MANSFIELD
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State | OH
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Zip | 44907
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Country | US
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Telephone | 419-756-2828
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | E3714
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License Number State | OH
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