Provider Demographics
NPI:1679818074
Name:RUSSELL, LAURA J (LLPC)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:MACKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 73972
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3972
Mailing Address - Country:US
Mailing Address - Phone:678-435-9949
Mailing Address - Fax:
Practice Address - Street 1:29 MILLARD FARMER IND BLVD
Practice Address - Street 2:SUITE B1
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5821
Practice Address - Country:US
Practice Address - Phone:678-435-9949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012348101YM0800X
GA008111101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health