Provider Demographics
NPI:1417282021
Name:RUSSELL, KAREN ELIZABETH (PCC-S, LCDC III)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:ELIZABETH
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PCC-S, LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4737
Mailing Address - Country:US
Mailing Address - Phone:419-557-5223
Mailing Address - Fax:419-557-5169
Practice Address - Street 1:1925 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4737
Practice Address - Country:US
Practice Address - Phone:419-557-5177
Practice Address - Fax:419-557-5169
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01110101YA0400X
OHE0003775101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH011110OtherLICENSED PROFESSIONAL CHEMICAL DEPENDENCY COUNSELOR III
OHE0003775OtherPROFESSIONAL CLINICAL COUNSELOR
ICADC 23847OtherINTERNATIONALLY CERTIFIED ALCOHOL AND DRUG COUNSELOR