Provider Demographics
NPI:1154924579
Name:RUSSELL, CHRISTY MARIE
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 V ST SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-5347
Mailing Address - Country:US
Mailing Address - Phone:360-995-3585
Mailing Address - Fax:
Practice Address - Street 1:908 5TH AVE SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1507
Practice Address - Country:US
Practice Address - Phone:360-878-4809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG61325552175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator