Provider Demographics
NPI:1831193812
Name:RUSSELL, PAMELA ANNE (LCSW, LPC)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:ANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 PINE MILL RD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-4938
Mailing Address - Country:US
Mailing Address - Phone:903-785-7410
Mailing Address - Fax:903-785-7721
Practice Address - Street 1:3435 PINE MILL RD
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-4938
Practice Address - Country:US
Practice Address - Phone:903-785-7410
Practice Address - Fax:903-785-7758
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX005701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S76JOtherBLUE CROSS BLUE SHIELD
TX108265302Medicaid
TX00S76JMedicare ID - Type UnspecifiedMEDICARE