Provider Demographics
NPI:1780135343
Name:RUSSELL, SARAH (LCDC-CI III)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCDC-CI III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 LAKESIDE ESTATES DR
Mailing Address - Street 2:#1612
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-2277
Mailing Address - Country:US
Mailing Address - Phone:832-314-8853
Mailing Address - Fax:
Practice Address - Street 1:1445 LAKESIDE ESTATES DR
Practice Address - Street 2:APT 1612
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-2277
Practice Address - Country:US
Practice Address - Phone:832-314-8853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14350101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)