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General NPI Number Information
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NPI Number | 1417465527
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Entity Type | Individual
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Provider Name | DESIREA RUSSELL MS, MBA, CRC, LPC
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Gender | Female
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Dates
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Enumeration Date | 01/11/2018
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Last Update Date | 02/08/2021
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Provider Practice Location Address
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Address Line | 2001 MARTIN LUTHER KING JR DR SW STE 201
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City | ATLANTA
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State | GA
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Zip | 30310-1101
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Country | US
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Telephone | 404-476-5498
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Fax |
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Provider Business Mailing Address
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Address Line | 2290 LAKE ROYALE DR
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City | RIVERDALE
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State | GA
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Zip | 30296-1896
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Country | US
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Telephone | 678-709-8002
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 009974
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License Number State | GA
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