Provider Demographics
NPI:1518622984
Name:RUSSOM, RICHELE RENE (LMHC)
Entity Type:Individual
Prefix:
First Name:RICHELE
Middle Name:RENE
Last Name:RUSSOM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SAN PEDRO DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6731
Mailing Address - Country:US
Mailing Address - Phone:505-823-4530
Mailing Address - Fax:505-823-4538
Practice Address - Street 1:1501 SAN PEDRO DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6731
Practice Address - Country:US
Practice Address - Phone:505-823-4530
Practice Address - Fax:505-823-4538
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0215911101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health