Provider Demographics
NPI:1437519576
Name:RUSSELL FOX, TYRA JEAN (LPCC)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:JEAN
Last Name:RUSSELL FOX
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15454
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-0454
Mailing Address - Country:US
Mailing Address - Phone:505-220-5809
Mailing Address - Fax:
Practice Address - Street 1:315 ALAMEDA BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2155
Practice Address - Country:US
Practice Address - Phone:505-220-5809
Practice Address - Fax:505-856-7946
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0206181101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health