Provider Demographics
NPI:1659560068
Name:RUSSELL, DIANA DEELANE (BS)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:DEELANE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 DYER ST
Mailing Address - Street 2:1
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4551
Mailing Address - Country:US
Mailing Address - Phone:931-560-4220
Mailing Address - Fax:931-560-4221
Practice Address - Street 1:115 DYER ST
Practice Address - Street 2:1
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4551
Practice Address - Country:US
Practice Address - Phone:931-560-4220
Practice Address - Fax:931-560-4221
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health