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NPI Code Detail

MEDICARE: MS. KAREN ELIZABETH RUSSELL PCC-S, LCDC III

MEDICARE: MS. KAREN ELIZABETH RUSSELL PCC-S, LCDC III
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
1101YA0400XAddiction (Substance Use Disorder) Counselor01110OH
2101YM0800XMental Health CounselorE0003775OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1011110OTHEROHLICENSED PROFESSIONAL CHEMICAL DEPENDENCY COUNSELOR III
2E0003775OTHEROHPROFESSIONAL CLINICAL COUNSELOR
3ICADC 23847OTHERINTERNATIONALLY CERTIFIED ALCOHOL AND DRUG COUNSELOR

General Provider Information

NPI Number : 1417282021
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. KAREN ELIZABETH RUSSELL PCC-S, LCDC III
Provider Business Mailing Address
First Line : 1925 HAYES AVE
Second Line :
City : SANDUSKY
State : OH
Zip : 44870-4737
Country : US
Telephone Number : 419-557-5223
Fax Number : 419-557-5169
Provider Business Practice Location Address
First Line : 1925 HAYES AVE
Second Line :
City : SANDUSKY
State : OH
Zip : 44870-4737
Country : US
Telephone Number : 419-557-5177
Fax Number : 419-557-5169
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/15/2009
Last Update Date : 10/15/2009

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