Provider Demographics
NPI:1598201352
Name:RUSSELL, BETHANY (MA, LPCC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4985 E 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-2501
Mailing Address - Country:US
Mailing Address - Phone:615-516-1371
Mailing Address - Fax:
Practice Address - Street 1:1780 S BELLAIRE ST
Practice Address - Street 2:SUITE 485
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-4307
Practice Address - Country:US
Practice Address - Phone:615-516-1371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0015092101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor