Provider Demographics
NPI:1598599854
Name:RUSSELL, CHASITY TIERRA (LMHC)
Entity type:Individual
Prefix:
First Name:CHASITY
Middle Name:TIERRA
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MRS
Other - First Name:CHASITY
Other - Middle Name:TIERRA
Other - Last Name:VAUGHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13008 NW COPPER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-3024
Mailing Address - Country:US
Mailing Address - Phone:706-573-7683
Mailing Address - Fax:
Practice Address - Street 1:7051 SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-5139
Practice Address - Country:US
Practice Address - Phone:561-296-5288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23676101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health