Provider Demographics
NPI:1861831653
Name:RUSSELL, KAHALA (LPC, CCAADC)
Entity Type:Individual
Prefix:
First Name:KAHALA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC, CCAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 FOREST PARK DR STE 122
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-1511
Mailing Address - Country:US
Mailing Address - Phone:912-335-7915
Mailing Address - Fax:888-417-8783
Practice Address - Street 1:6815 FOREST PARK DR STE 122
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-1511
Practice Address - Country:US
Practice Address - Phone:912-335-7915
Practice Address - Fax:888-417-8783
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC0117101YA0400X
GALPC007127101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)