Provider Demographics
NPI:1689359937
Name:CORREA, RUSSELL (EDM,, LMHC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:CORREA
Suffix:
Gender:M
Credentials:EDM,, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16110 SW 91ST CT
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3599
Mailing Address - Country:US
Mailing Address - Phone:786-457-5371
Mailing Address - Fax:
Practice Address - Street 1:16110 SW 91ST CT
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-3599
Practice Address - Country:US
Practice Address - Phone:786-457-5371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15672101YM0800X
NY001465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health