Provider Demographics
NPI:1194861666
Name:RUSSELL, ROBERT DAVID JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DAVID
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 THORNBUSH CT
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-5442
Mailing Address - Country:US
Mailing Address - Phone:770-439-6926
Mailing Address - Fax:
Practice Address - Street 1:6488 SPRING ST
Practice Address - Street 2:SUITE 201
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-1895
Practice Address - Country:US
Practice Address - Phone:770-949-1595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004424101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional