Provider Demographics
NPI:1417453820
Name:RUSSELL, LESLIE LINNEA (CADC)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:LINNEA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 N LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:50849-8234
Mailing Address - Country:US
Mailing Address - Phone:641-745-7520
Mailing Address - Fax:
Practice Address - Street 1:1003 COTTONWOOD RD
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-1012
Practice Address - Country:US
Practice Address - Phone:641-782-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16024101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)