Provider Demographics
NPI:1487793907
Name:RUSSELL, SUSAN M (LCPC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 BEECHWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:ME
Mailing Address - Zip Code:04468-9749
Mailing Address - Country:US
Mailing Address - Phone:207-827-8977
Mailing Address - Fax:
Practice Address - Street 1:319 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4607
Practice Address - Country:US
Practice Address - Phone:207-942-2199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC 2971101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME231900099Medicaid