Provider Information for 1720498785
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Mr. CORY ANTHONY RUSSELL LPCi
Other Names:Professional Name:Mr. CORY ANTHONY RUSSELL LPCSex: Male
NPI: 1720498785
Last Updated: 2015-05-26
Certification Date:
Certification Date:
Details
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NPI | 1720498785 | ||||||||
Enumeration Date | 2014-04-30 | ||||||||
NPI Type | NPI-1 Individual | ||||||||
Sole Proprietor | NO | ||||||||
Status | Active | ||||||||
Mailing Address | 1050 RIBAUT RD BEAUFORT, SC 29902-5400 United States Phone: 843-524-8899 | Fax: | ||||||||
Primary Practice Address | 438 BARNWELL RD ALLENDALE, SC 29810 United States Phone: 803-584-4636 | Fax: | ||||||||
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