Provider Demographics
NPI:1851923858
Name:RUSSELL, KIRSTEN CHARMAIN
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:CHARMAIN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11263 OLD 63 S APT 59
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-6656
Mailing Address - Country:US
Mailing Address - Phone:601-508-9131
Mailing Address - Fax:
Practice Address - Street 1:57 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6583
Practice Address - Country:US
Practice Address - Phone:601-947-4274
Practice Address - Fax:601-947-4275
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000181214Medicaid