Provider Demographics
NPI:1477962678
Name:RUSSELL, ALECIA MARIE (EDD)
Entity Type:Individual
Prefix:DR
First Name:ALECIA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 SHADY LANE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230
Mailing Address - Country:US
Mailing Address - Phone:614-365-5391
Mailing Address - Fax:614-365-5390
Practice Address - Street 1:1444 SHADY LANE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2110
Practice Address - Country:US
Practice Address - Phone:614-365-5391
Practice Address - Fax:614-365-5390
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCL1010787103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool