Provider Demographics
NPI:1427659853
Name:RUSSELL, TAMIKA D (LPC)
Entity type:Individual
Prefix:
First Name:TAMIKA
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:TAMIKA
Other - Middle Name:D
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:938 MARISA LN
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-3880
Mailing Address - Country:US
Mailing Address - Phone:214-799-0045
Mailing Address - Fax:
Practice Address - Street 1:938 MARISA LN
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-3880
Practice Address - Country:US
Practice Address - Phone:214-799-0045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81523101YP2500X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX418990401Medicaid
TX4056772Medicaid