Provider Demographics
NPI:1184045379
Name:RUSSELL, SUSAN ELIZABETH (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9620
Mailing Address - Country:US
Mailing Address - Phone:231-459-5606
Mailing Address - Fax:
Practice Address - Street 1:201 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9620
Practice Address - Country:US
Practice Address - Phone:231-459-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-15
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013753101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor