Provider Demographics
NPI:1235310178
Name:SEMON, RUSSELL GLENN (LPC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:GLENN
Last Name:SEMON
Suffix:
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 1:10008 FERRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8406
Mailing Address - Country:US
Mailing Address - Phone:318-773-0103
Mailing Address - Fax:318-676-5086
Practice Address - Street 1:10008 FERRY CREEK DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8406
Practice Address - Country:US
Practice Address - Phone:318-773-0103
Practice Address - Fax:318-676-5086
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2654101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health