Provider Demographics
NPI:1184320004
Name:RUSSELL, LABREA (LAPC)
Entity type:Individual
Prefix:
First Name:LABREA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:LABREA
Other - Middle Name:
Other - Last Name:O'NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAPC
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-0004
Mailing Address - Country:US
Mailing Address - Phone:404-418-2190
Mailing Address - Fax:
Practice Address - Street 1:770 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3380
Practice Address - Country:US
Practice Address - Phone:404-418-2190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC0075551101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional