Provider Demographics
NPI:1043509573
Name:RUSSELL, MARY TEISITA
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:TEISITA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-3840
Mailing Address - Country:US
Mailing Address - Phone:580-335-1079
Mailing Address - Fax:
Practice Address - Street 1:70 N 31ST ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-9116
Practice Address - Country:US
Practice Address - Phone:580-323-2061
Practice Address - Fax:580-323-5635
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health