Provider Demographics
NPI:1134457187
Name:RUSSUM, MICHELLE DAWN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DAWN
Last Name:RUSSUM
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 1:2 W 42ND ST STE 3200
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4669
Mailing Address - Country:US
Mailing Address - Phone:308-635-3888
Mailing Address - Fax:
Practice Address - Street 1:2 W 42ND ST STE 3200
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4669
Practice Address - Country:US
Practice Address - Phone:308-635-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2473101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional