Provider Demographics
NPI:1801123427
Name:RUSSELL, ROSLYN YVONNE (MS, LPC)
Entity type:Individual
Prefix:MS
First Name:ROSLYN
Middle Name:YVONNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416A TIMMY LN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-9419
Mailing Address - Country:US
Mailing Address - Phone:252-678-0309
Mailing Address - Fax:
Practice Address - Street 1:416A TIMMY LN
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-9419
Practice Address - Country:US
Practice Address - Phone:252-678-0309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7562101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health