Provider Demographics
NPI:1326550393
Name:RUSSELL, PENNY JO (LCDCII)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JO
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-1040
Mailing Address - Country:US
Mailing Address - Phone:740-484-4141
Mailing Address - Fax:740-484-4143
Practice Address - Street 1:116 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:OH
Practice Address - Zip Code:43718-9593
Practice Address - Country:US
Practice Address - Phone:740-484-4141
Practice Address - Fax:740-484-4143
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH981062101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)