Provider Demographics
NPI:1841404159
Name:RUSSELL, CHARLES EDWARD (MA, LPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDWARD
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 A STREET RD
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-1747
Mailing Address - Country:US
Mailing Address - Phone:970-566-0510
Mailing Address - Fax:970-221-2727
Practice Address - Street 1:1644 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1007
Practice Address - Country:US
Practice Address - Phone:970-221-0999
Practice Address - Fax:970-221-0999
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC 4285101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31800335Medicaid