MEDICARE: ANNIE RUSSELL 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	101YP1600X	Pastoral Counselor
2	101YP2500X	Professional Counselor	LPC009369	GA

General Provider Information

NPI Number	:	1346785888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNIE RUSSELL LPC

Provider Business Mailing Address
First Line	:	4720 PEACHTREE INDUSTRIAL BLVD STE 4202
Second Line	:
City	:	BERKELEY LAKE
State	:	GA
Zip	:	30071-5738
Country	:	US
Telephone Number	:	678-336-6128
Fax Number	:

Provider Business Practice Location Address
First Line	:	4720 PEACHTREE INDUSTRIAL BLVD STE 4202
Second Line	:
City	:	BERKELEY LAKE
State	:	GA
Zip	:	30071-5738
Country	:	US
Telephone Number	:	678-336-6128
Fax Number	:

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

Provider Enumeration Date	:	12/19/2016
Last Update Date	:	07/18/2024

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