Provider Demographics
NPI:1497057558
Name:GILLETTE, RUSSELL O (LPC, LADC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:O
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-4220
Mailing Address - Country:US
Mailing Address - Phone:405-527-1785
Mailing Address - Fax:405-527-1084
Practice Address - Street 1:1008 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4734
Practice Address - Country:US
Practice Address - Phone:918-458-0113
Practice Address - Fax:918-458-0075
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK271101YA0400X
OK2303101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)