Provider Demographics
NPI:1558839746
Name:RUSSELL, KRISTINA (LPC, LLMFT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 FAIRFIELD AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3746
Mailing Address - Country:US
Mailing Address - Phone:616-260-3634
Mailing Address - Fax:
Practice Address - Street 1:3351 CLAYSTONE ST SE STE G-32
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5794
Practice Address - Country:US
Practice Address - Phone:616-288-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016900101Y00000X
MI4101006827106H00000X
MI6401019274101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist