Provider Demographics
NPI:1205606134
Name:MICHAILOFF-RUSSELL, KIERA CAMILLE (LAC)
Entity type:Individual
Prefix:
First Name:KIERA
Middle Name:CAMILLE
Last Name:MICHAILOFF-RUSSELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 S COLLEGE AVE STE 4B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5344
Mailing Address - Country:US
Mailing Address - Phone:479-966-9896
Mailing Address - Fax:
Practice Address - Street 1:28 S COLLEGE AVE STE 4B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5344
Practice Address - Country:US
Practice Address - Phone:479-966-9896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2312011101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional