Provider Demographics
NPI:1013447242
Name:MYNHIER, RUSSELL E (MSED, LMFT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:MYNHIER
Suffix:
Gender:M
Credentials:MSED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6319 MUTUAL DR STE F
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4246
Mailing Address - Country:US
Mailing Address - Phone:260-209-4473
Mailing Address - Fax:
Practice Address - Street 1:6319 MUTUAL DR STE F
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-4246
Practice Address - Country:US
Practice Address - Phone:260-209-4473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IN35002070A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor