Provider Demographics
NPI:1548773831
Name:RUSSELL, MICHAEL FRANK (COUNSELOR)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FRANK
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-7046
Mailing Address - Country:US
Mailing Address - Phone:804-213-0249
Mailing Address - Fax:
Practice Address - Street 1:2217 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7046
Practice Address - Country:US
Practice Address - Phone:804-213-0249
Practice Address - Fax:804-716-0715
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1341101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)