Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | 6401010247 | MI |
N | 101YM0800X | Mental Health Counselor | 6401010247 | MI |
N | 101YP1600X | Pastoral Counselor | 6401010247 | MI |
Y | 101YP2500X | Professional Counselor | 6401010247 | MI |
NPI | 1366642761 |
---|---|
Provider Name | Stanley Wayne Russell |
First Address | Battle Creek, MI 49015-7948 |
Second Address | Battle Creek, MI 49015-7948 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/07/2007 |
Last Update Date | 02/02/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
6401010247 | STATE OF MICHIGAN LICENSED PROFESSIONAL COUNSELOR (01) | MI |