Provider Demographics
NPI:1467127175
Name:RUSSELL, CHALLIS EVELYN (MA, LPC)
Entity Type:Individual
Prefix:
First Name:CHALLIS
Middle Name:EVELYN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 MCDONALD CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-6134
Mailing Address - Country:US
Mailing Address - Phone:843-294-0646
Mailing Address - Fax:843-294-0318
Practice Address - Street 1:141 MCDONALD CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-6134
Practice Address - Country:US
Practice Address - Phone:843-294-0646
Practice Address - Fax:843-294-0318
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7920101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7920OtherLPC.7920 PC