Provider Demographics
NPI:1396377917
Name:RUSSELL, LAURA RENAY (CMHC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:RENAY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5414 DAYBREAK PKWY
Mailing Address - Street 2:C-4 #123
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009
Mailing Address - Country:US
Mailing Address - Phone:385-355-0830
Mailing Address - Fax:385-308-7477
Practice Address - Street 1:5414 DAYBREAK PKWY
Practice Address - Street 2:C-4 #123
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009
Practice Address - Country:US
Practice Address - Phone:385-355-0830
Practice Address - Fax:385-308-7477
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10322316-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health