Provider Demographics
NPI:1336479542
Name:RUSSELL, PANOLA E (LCPC CCBT LCAC)
Entity Type:Individual
Prefix:MRS
First Name:PANOLA
Middle Name:E
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCPC CCBT LCAC
Other - Prefix:MRS
Other - First Name:PANOLA
Other - Middle Name:E
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:855 BURNHAM DR APT F
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60484-3042
Mailing Address - Country:US
Mailing Address - Phone:708-534-7559
Mailing Address - Fax:
Practice Address - Street 1:855 BURNHAM DR APT F
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PARK
Practice Address - State:IL
Practice Address - Zip Code:60484-3042
Practice Address - Country:US
Practice Address - Phone:708-534-7559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 103K00000X
IN87001334A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)