Provider Demographics
NPI:1679855712
Name:RUSSELMAN, DOMINIQUE M
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:M
Last Name:RUSSELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58646 MCNULTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-6210
Mailing Address - Country:US
Mailing Address - Phone:503-397-5211
Mailing Address - Fax:503-397-5373
Practice Address - Street 1:271 COLUMBIA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-2021
Practice Address - Country:US
Practice Address - Phone:503-397-0391
Practice Address - Fax:503-366-1067
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health