Provider Demographics
NPI:1487135588
Name:RUSSELL, TONIE L (CDCA)
Entity type:Individual
Prefix:MISS
First Name:TONIE
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 WOODLAND AVE STE 703
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-2775
Mailing Address - Country:US
Mailing Address - Phone:216-431-2018
Mailing Address - Fax:216-350-7183
Practice Address - Street 1:6001 WOODLAND AVE STE 703
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-2775
Practice Address - Country:US
Practice Address - Phone:216-431-2018
Practice Address - Fax:216-350-7183
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.167170101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty