Provider Demographics
NPI:1356995740
Name:RUSSELL, KACEE (LCPC)
Entity type:Individual
Prefix:
First Name:KACEE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KACEE
Other - Middle Name:
Other - Last Name:DONALDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:5040 FREEMONT RD
Mailing Address - Street 2:
Mailing Address - City:NEW PLYMOUTH
Mailing Address - State:ID
Mailing Address - Zip Code:83655-5425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28371 EL PASO RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-7521
Practice Address - Country:US
Practice Address - Phone:208-454-8847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC7175101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health