Provider Demographics
NPI:1891911400
Name:RUSS, RYAN (LAC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:RUSS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MEGHAN LN
Mailing Address - Street 2:
Mailing Address - City:JUDSONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72081-9302
Mailing Address - Country:US
Mailing Address - Phone:501-729-4479
Mailing Address - Fax:501-729-3537
Practice Address - Street 1:120 MEGHAN LN
Practice Address - Street 2:
Practice Address - City:JUDSONIA
Practice Address - State:AR
Practice Address - Zip Code:72081
Practice Address - Country:US
Practice Address - Phone:501-729-4479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0609056101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional