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General NPI Number Information
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NPI Number | 1396377917
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Entity Type | Individual
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Provider Name | LAURA RENAY RUSSELL CMHC
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Gender | Female
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Dates
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Enumeration Date | 02/11/2020
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Last Update Date | 08/14/2023
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Provider Practice Location Address
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Address Line | 5414 DAYBREAK PKWY C-4 #123
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City | SOUTH JORDAN
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State | UT
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Zip | 84009
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Country | US
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Telephone | 385-355-0830
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Fax | 385-308-7477
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Provider Business Mailing Address
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Address Line | 5414 DAYBREAK PKWY C-4 #123
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City | SOUTH JORDAN
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State | UT
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Zip | 84009
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Country | US
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Telephone | 385-355-0830
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Fax | 385-308-7477
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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 | 10322316-6004
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License Number State | UT
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