Provider Demographics
NPI:1255090353
Name:RUSSELL, LAVONNE LENAIR (LCASA)
Entity type:Individual
Prefix:
First Name:LAVONNE
Middle Name:LENAIR
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 CROYDON LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-6810
Mailing Address - Country:US
Mailing Address - Phone:336-473-8439
Mailing Address - Fax:
Practice Address - Street 1:408 CROYDON LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-6810
Practice Address - Country:US
Practice Address - Phone:336-473-8439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26842101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)