Provider Demographics
NPI:1790084739
Name:RUSS-WILLIAMS, ERNESTINE MICHELLE (LAC, CRC)
Entity Type:Individual
Prefix:
First Name:ERNESTINE
Middle Name:MICHELLE
Last Name:RUSS-WILLIAMS
Suffix:
Gender:F
Credentials:LAC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W B AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-9180
Mailing Address - Country:US
Mailing Address - Phone:501-249-4056
Mailing Address - Fax:
Practice Address - Street 1:1005 W B AVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-9180
Practice Address - Country:US
Practice Address - Phone:501-249-4056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA1101012101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional