Provider Demographics
NPI:1265242259
Name:RUSSELL, TOMMY (LPC A)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPC A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 INDUSTRIAL LOOP STE 900
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-5463
Mailing Address - Country:US
Mailing Address - Phone:803-998-8710
Mailing Address - Fax:
Practice Address - Street 1:103 INDUSTRIAL LOOP STE 900
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-5463
Practice Address - Country:US
Practice Address - Phone:803-998-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X
TX96618101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral