=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487793907
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN M. RUSSELL LCPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 06/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 319 UNION ST
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-4607
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-942-2199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 BEECHWOOD AVE
-----------------------------------------------------
City | OLD TOWN
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04468-9749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-827-8977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CC 2971
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------