Provider Demographics
NPI:1891048906
Name:MULLETT, RUSSELL C (MED, LCPC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:C
Last Name:MULLETT
Suffix:
Gender:M
Credentials:MED, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:IL
Mailing Address - Zip Code:60957-1663
Mailing Address - Country:US
Mailing Address - Phone:217-722-0231
Mailing Address - Fax:
Practice Address - Street 1:1801 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7236
Practice Address - Country:US
Practice Address - Phone:217-693-4529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006850101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional