Provider Demographics
NPI:1710274931
Name:RUSSELL, DEE A (LCSW, LCAC, LISW)
Entity Type:Individual
Prefix:MS
First Name:DEE
Middle Name:A
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW, LCAC, LISW
Other - Prefix:MS
Other - First Name:DEE
Other - Middle Name:A
Other - Last Name:DIEHL-KELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW, LCAC, LISW
Mailing Address - Street 1:3354 ROAD 124
Mailing Address - Street 2:
Mailing Address - City:PAYNE
Mailing Address - State:OH
Mailing Address - Zip Code:45880-9101
Mailing Address - Country:US
Mailing Address - Phone:260-223-7545
Mailing Address - Fax:
Practice Address - Street 1:3354 ROAD 124
Practice Address - Street 2:
Practice Address - City:PAYNE
Practice Address - State:OH
Practice Address - Zip Code:45880-9101
Practice Address - Country:US
Practice Address - Phone:260-223-7545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006134A1041C0700X
IN87001352A101YA0400X
OHI14401601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)