Provider Demographics
NPI:1689734527
Name:RUSS, MARILYNN LOUISE (MS LMHC CERTIFIED SC)
Entity Type:Individual
Prefix:MRS
First Name:MARILYNN
Middle Name:LOUISE
Last Name:RUSS
Suffix:
Gender:F
Credentials:MS LMHC CERTIFIED SC
Other - Prefix:MISS
Other - First Name:MARILYN
Other - Middle Name:LOUISE
Other - Last Name:KUMMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS
Mailing Address - Street 1:13792 85TH AVE
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-9079
Mailing Address - Country:US
Mailing Address - Phone:641-777-1771
Mailing Address - Fax:641-683-1149
Practice Address - Street 1:611 CHURCH STREET
Practice Address - Street 2:SUITE #103
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-9079
Practice Address - Country:US
Practice Address - Phone:641-777-1771
Practice Address - Fax:641-683-1149
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00453101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIP541044Medicaid