Provider Demographics
NPI:1922251933
Name:RUSS, YVONNE MARIE (LPC, CMAC)
Entity Type:Individual
Prefix:MS
First Name:YVONNE
Middle Name:MARIE
Last Name:RUSS
Suffix:
Gender:F
Credentials:LPC, CMAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 THE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1186
Mailing Address - Country:US
Mailing Address - Phone:706-573-1058
Mailing Address - Fax:
Practice Address - Street 1:124 THE RIDGE CT
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1186
Practice Address - Country:US
Practice Address - Phone:706-573-1058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010434101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1628-ROtherCERTIFIED ADDICTION COUNSELOR