Provider Demographics
NPI:1376727446
Name:RUSSELL, THOMAS A (MA, MED, PCCS)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MA, MED, PCCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 LEXINGTON AVENUE
Mailing Address - Street 2:HERITAGE CHRISTIAN COUNSELING MINISTRIES
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907
Mailing Address - Country:US
Mailing Address - Phone:419-756-2828
Mailing Address - Fax:
Practice Address - Street 1:788 LEXINGTON AVENUE
Practice Address - Street 2:HERITAGE CHRISTIAN COUNSELING MINISTRIES
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907
Practice Address - Country:US
Practice Address - Phone:419-756-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE3714101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health