Provider Demographics
NPI:1366642761
Name:RUSSELL, STANLEY WAYNE (LPC)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:WAYNE
Last Name:RUSSELL
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 1:4625 BECKLEY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-7948
Mailing Address - Country:US
Mailing Address - Phone:269-979-8119
Mailing Address - Fax:
Practice Address - Street 1:4625 BECKLEY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-7948
Practice Address - Country:US
Practice Address - Phone:269-979-8119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010247101Y00000X, 101YM0800X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401010247OtherSTATE OF MICHIGAN LICENSED PROFESSIONAL COUNSELOR