Provider Demographics
NPI:1568501187
Name:RUSSELL, DELISA DUNCAN (LPC-S)
Entity Type:Individual
Prefix:
First Name:DELISA
Middle Name:DUNCAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 OTTER POND PL
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77381-4011
Mailing Address - Country:US
Mailing Address - Phone:210-725-7716
Mailing Address - Fax:
Practice Address - Street 1:147 W SUNSET RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2681
Practice Address - Country:US
Practice Address - Phone:210-725-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15324101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1529836-01Medicaid