Provider Demographics
NPI:1588984603
Name:RUSSELL, NICHOLAS AARON (LPCC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:AARON
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3122 SUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4062
Mailing Address - Country:US
Mailing Address - Phone:575-404-1593
Mailing Address - Fax:
Practice Address - Street 1:1909 CUBA AVE STE 1
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5646
Practice Address - Country:US
Practice Address - Phone:575-404-1593
Practice Address - Fax:575-404-1593
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0700288S101Y00000X, 101YM0800X
NM0206781101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
14499905OtherCAQH
NM47279061Medicaid
OHE0700288SOtherSTATE OF OHIO COUNSELOR SOCIAL WORK MARRIAGE AND FAMILY THERAPIST BOARD
NMCCMH0206781OtherCOUNSELING AND THERAPY PRACTICE BOARD OF NEW MEXICO