Provider Demographics
NPI:1043980139
Name:RUSSELL, DOMINIQUE (MA,LPC)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 W RIDGE RD LOT 214
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-1333
Mailing Address - Country:US
Mailing Address - Phone:312-632-0460
Mailing Address - Fax:
Practice Address - Street 1:4520 W RIDGE RD LOT 214
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-1333
Practice Address - Country:US
Practice Address - Phone:312-632-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017417101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional