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General NPI Number Information
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NPI Number | 1558839746
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Entity Type | Individual
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Provider Name | KRISTINA RUSSELL LPC, LLMFT
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Gender | Female
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Dates
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Enumeration Date | 11/06/2018
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Last Update Date | 04/27/2021
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Provider Practice Location Address
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Address Line | 3351 CLAYSTONE ST SE STE G-32
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-5794
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Country | US
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Telephone | 616-288-2558
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Fax |
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Provider Business Mailing Address
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Address Line | 918 FAIRFIELD AVE NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49504-3746
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Country | US
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Telephone | 616-260-3634
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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 | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 6401016900
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4101006827
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401019274
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License Number State | MI
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