Provider Demographics
NPI:1346785888
Name:RUSSELL, ANNIE (LPC)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4530 S BERKELEY LAKE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BERKELEY LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1660
Mailing Address - Country:US
Mailing Address - Phone:678-336-6128
Mailing Address - Fax:770-446-5643
Practice Address - Street 1:4530 S BERKELEY LAKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:BERKELEY LAKE
Practice Address - State:GA
Practice Address - Zip Code:30071-1660
Practice Address - Country:US
Practice Address - Phone:678-336-6128
Practice Address - Fax:770-446-5643
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
GALPC009369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral