Provider Demographics
NPI:1407537442
Name:LACELLE, RUSSELL JOSEPH II (LVT, CORPORAL)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JOSEPH
Last Name:LACELLE
Suffix:II
Gender:M
Credentials:LVT, CORPORAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19649 JOLGREN DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-2259
Mailing Address - Country:US
Mailing Address - Phone:586-909-9875
Mailing Address - Fax:
Practice Address - Street 1:19649 JOLGREN DR
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-2259
Practice Address - Country:US
Practice Address - Phone:586-909-9875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator