Provider Demographics
NPI:1376331942
Name:RUSSELL, KENDRA
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109641 S 4157 RD
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426-2375
Mailing Address - Country:US
Mailing Address - Phone:918-843-2857
Mailing Address - Fax:
Practice Address - Street 1:436 COURT ST STE B
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6303
Practice Address - Country:US
Practice Address - Phone:918-310-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No174400000XOther Service ProvidersSpecialist