=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639627920
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICA ELIZABETH RUSSELL LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2016
-----------------------------------------------------
Last Update Date | 08/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2305 E PARIS AVE SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-481-3784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2275 FAWNWOOD DR SE
-----------------------------------------------------
City | KENTWOOD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-945-5313
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401015661
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------