Provider Demographics
NPI:1457310039
Name:RUSSELL, ALINE GASTON (DMIN, LCPC, LMFT)
Entity Type:Individual
Prefix:DR
First Name:ALINE
Middle Name:GASTON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DMIN, LCPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 MCKINLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-3357
Mailing Address - Country:US
Mailing Address - Phone:618-462-1510
Mailing Address - Fax:
Practice Address - Street 1:1710 CLAWSON ST
Practice Address - Street 2:#4
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4792
Practice Address - Country:US
Practice Address - Phone:618-462-1448
Practice Address - Fax:314-878-4524
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist