Provider Demographics
NPI:1609206960
Name:RUSSELL, DANIELLE NICOLE (MED)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N POLK ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-4240
Mailing Address - Country:US
Mailing Address - Phone:573-690-4511
Mailing Address - Fax:
Practice Address - Street 1:718 W MCCARTY ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-1544
Practice Address - Country:US
Practice Address - Phone:573-690-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013041568101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor