Provider Demographics
NPI:1942019310
Name:KYLIE RUSSELL
Entity type:Organization
Organization Name:KYLIE RUSSELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:319-406-2561
Mailing Address - Street 1:PO BOX 71602
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-0602
Mailing Address - Country:US
Mailing Address - Phone:515-243-2057
Mailing Address - Fax:
Practice Address - Street 1:2302 W 1ST ST STE 109
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-1854
Practice Address - Country:US
Practice Address - Phone:319-406-2561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-31
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty