Provider Demographics
NPI:1821360603
Name:VINER, RUSSELL SHANE (LPC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:SHANE
Last Name:VINER
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:PO BOX 1251
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-1251
Mailing Address - Country:US
Mailing Address - Phone:662-226-3762
Mailing Address - Fax:
Practice Address - Street 1:501 SOUTHWEST FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-0000
Practice Address - Country:US
Practice Address - Phone:662-226-3762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0563101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional