Provider Demographics
NPI:1003394180
Name:RUSSELL, GARY LEE (LPCC-S, LICDC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPCC-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 S LEXINGTON SPRINGMILL RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-1325
Mailing Address - Country:US
Mailing Address - Phone:419-528-8008
Mailing Address - Fax:877-486-1420
Practice Address - Street 1:151 MARION AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2223
Practice Address - Country:US
Practice Address - Phone:419-774-9969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162577101YA0400X
OHE.2001844-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty