Provider Demographics
NPI:1427868181
Name:RUSSELL, ELLIE CLAIRE (IMT4219)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:CLAIRE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:IMT4219
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 110TH AVE N APT 510
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3153
Mailing Address - Country:US
Mailing Address - Phone:615-878-5775
Mailing Address - Fax:
Practice Address - Street 1:715 N WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-4256
Practice Address - Country:US
Practice Address - Phone:941-876-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT4219106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist