Provider Demographics
NPI:1861370488
Name:GREGORY, RUSSELL (MA,LPC-A)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:GREGORY
Suffix:
Gender:M
Credentials:MA,LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4769 VAN ZANDT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6180
Mailing Address - Country:US
Mailing Address - Phone:817-903-4239
Mailing Address - Fax:
Practice Address - Street 1:1785 STATE HIGHWAY 26 STE 200
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-2217
Practice Address - Country:US
Practice Address - Phone:682-231-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-22
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX95558101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional