Provider Demographics
NPI:1346572591
Name:RUSSELL, MIRANDA (LMHSP)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 TREADWAY CIR
Mailing Address - Street 2:
Mailing Address - City:THORN HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37881-5039
Mailing Address - Country:US
Mailing Address - Phone:423-733-9359
Mailing Address - Fax:865-767-3076
Practice Address - Street 1:105 ROWDY ROW
Practice Address - Street 2:
Practice Address - City:BEAN STATION
Practice Address - State:TN
Practice Address - Zip Code:37708
Practice Address - Country:US
Practice Address - Phone:865-767-3074
Practice Address - Fax:865-767-3076
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2347101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health