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General NPI Number Information
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NPI Number | 1720232804
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Entity Type | Organization
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Legal Business Name | MAXINE RUSSELL PHD LLC
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Dates
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Enumeration Date | 11/16/2008
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Last Update Date | 11/16/2008
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Provider Practice Location Address
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Address Line | 1415 PANTHER LN SUITE 216
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City | NAPLES
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State | FL
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Zip | 34109-7874
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Country | US
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Telephone | 239-591-6636
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Fax | 239-591-6637
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Provider Business Mailing Address
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Address Line | 1415 PANTHER LN SUITE 216
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City | NAPLES
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State | FL
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Zip | 34109-7874
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Country | US
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Telephone | 239-591-6636
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Fax | 239-591-6637
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Authorized Official
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Title or Position | MENTAL HEALTH COUNSELOR
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Name | DR. MAXINE M. RUSSELL
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Credential | PH.D.
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Telephone | 239-591-6636
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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 | MH4166
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License Number State | FL
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