MEDICARE: MICHELE R RUSS MBS, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1235388000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE R RUSS MBS, LPC

Provider Business Mailing Address
First Line	:	PO BOX 189
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73402-0189
Country	:	US
Telephone Number	:	409-798-4523
Fax Number	:

Provider Business Practice Location Address
First Line	:	1219 K ST NW STE 2
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1801
Country	:	US
Telephone Number	:	580-798-4523
Fax Number	:	580-319-5349

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	12/02/2024

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