Provider Demographics
NPI:1831184498
Name:RUSSELL, MYLINDA ORENE (SR PSYCH EXAMINER)
Entity type:Individual
Prefix:MS
First Name:MYLINDA
Middle Name:ORENE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:SR PSYCH EXAMINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 S HOME ST
Mailing Address - Street 2:P.O. BOX 0057
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5748
Mailing Address - Country:US
Mailing Address - Phone:731-885-0201
Mailing Address - Fax:731-884-2998
Practice Address - Street 1:1413 S HOME ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5748
Practice Address - Country:US
Practice Address - Phone:731-885-0201
Practice Address - Fax:731-884-2998
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNSLPE 1414101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional