Provider Demographics
NPI:1134171945
Name:RUSSELL, TERESA MARIE (PSYD, LCPC, LCADC)
Entity type:Individual
Prefix:DR
First Name:TERESA
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:
Credentials:PSYD, LCPC, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10299 REINDEER PL
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:MD
Mailing Address - Zip Code:21774-6818
Mailing Address - Country:US
Mailing Address - Phone:240-575-1206
Mailing Address - Fax:
Practice Address - Street 1:10299 REINDEER PL
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6818
Practice Address - Country:US
Practice Address - Phone:240-575-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC5788101YP2500X
FLTPMC80101YP2500X
NVCP000009101Y00000X, 101YP2500X
HIMHC863101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD074657600Medicaid
NV100507626Medicaid