Provider Demographics
NPI:1801946405
Name:RUSSELL, MARY KATHERINE (LMFT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5790 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1874
Mailing Address - Country:US
Mailing Address - Phone:909-855-0302
Mailing Address - Fax:
Practice Address - Street 1:6711 ARLINGTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-1955
Practice Address - Country:US
Practice Address - Phone:951-352-4964
Practice Address - Fax:951-352-4965
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 36287101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health