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Provider Information for 1720498785


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Mr. CORY ANTHONY RUSSELL LPCi


Other Names:  
Professional Name: 
Mr. CORY ANTHONY RUSSELL LPC

Sex: Male

NPI: 1720498785
Last Updated: 2015-05-26
Certification Date:

Details

NameValue
NPI1720498785
Enumeration Date2014-04-30
NPI TypeNPI-1 Individual
Sole ProprietorNO
StatusActive
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:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
Yes 101YM0800X - Counselor - Mental HealthSC6131