Provider Demographics
NPI:1225603822
Name:RUSSELL, DAWN R (MA)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6910 N MAIN ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9681
Mailing Address - Country:US
Mailing Address - Phone:574-931-2680
Mailing Address - Fax:574-931-2679
Practice Address - Street 1:6910 N MAIN ST UNIT 4
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-9681
Practice Address - Country:US
Practice Address - Phone:574-931-2680
Practice Address - Fax:574-931-2679
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health