Provider Demographics
NPI:1760777569
Name:RUSSELL, DANE (LPC)
Entity Type:Individual
Prefix:
First Name:DANE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S MOLINE ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-1274
Mailing Address - Country:US
Mailing Address - Phone:303-909-5692
Mailing Address - Fax:
Practice Address - Street 1:3222 S JEBEL WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-9014
Practice Address - Country:US
Practice Address - Phone:303-909-5692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1995101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional