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NPI Code Detail

MEDICARE: NICOLE LEE RUSSELL MPA, CADC

MEDICARE: NICOLE LEE RUSSELL MPA, CADC
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) Counselor25054IA

General Provider Information

NPI Number : 1831981125
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE LEE RUSSELL MPA, CADC
Provider Business Mailing Address
First Line : 1431 INGERSOLL RD
Second Line :
City : WATERLOO
State : IA
Zip : 50701-6047
Country : US
Telephone Number : 319-239-4203
Fax Number :
Provider Business Practice Location Address
First Line : 405 E 5TH ST
Second Line :
City : WATERLOO
State : IA
Zip : 50703-5705
Country : US
Telephone Number : 319-239-4203
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/21/2025
Last Update Date : 05/21/2025

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