Provider Demographics
NPI:1093047854
Name:RUSSELL, DOROTHY K (ATR-BC)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5517 BRINSON DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-2729
Mailing Address - Country:US
Mailing Address - Phone:502-409-3826
Mailing Address - Fax:
Practice Address - Street 1:5517 BRINSON DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2729
Practice Address - Country:US
Practice Address - Phone:502-409-3826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPAT 161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health