Provider Demographics
NPI:1003093055
Name:RUSSELL, DIANE MARY (MS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 S 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8435
Mailing Address - Country:US
Mailing Address - Phone:471-581-4849
Mailing Address - Fax:417-581-4839
Practice Address - Street 1:4699 N 21ST ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7684
Practice Address - Country:US
Practice Address - Phone:417-581-4849
Practice Address - Fax:417-581-4839
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008001153101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional