Provider Demographics
NPI:1720498785
Name:RUSSELL, CORY ANTHONY (LPCI)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:ANTHONY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LPCI
Other - Prefix:MR
Other - First Name:CORY
Other - Middle Name:ANTHONY
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:1050 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5400
Mailing Address - Country:US
Mailing Address - Phone:843-524-8899
Mailing Address - Fax:
Practice Address - Street 1:438 BARNWELL RD
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:SC
Practice Address - Zip Code:29810
Practice Address - Country:US
Practice Address - Phone:803-584-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6131101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health