Provider Demographics
NPI:1699197707
Name:RUSSELL, LEANNE K (LPC)
Entity Type:Individual
Prefix:MRS
First Name:LEANNE
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3123
Mailing Address - Country:US
Mailing Address - Phone:620-792-2544
Mailing Address - Fax:620-792-7052
Practice Address - Street 1:5815 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3123
Practice Address - Country:US
Practice Address - Phone:620-792-2544
Practice Address - Fax:620-792-7052
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC435201Medicaid
SC3348Medicare PIN