Basic Information
| Provider Information | |||||||||
| NPI: | 1023286481 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | KRISTY | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 2239 S CARAWAY RD | ||||||||
| Address2: | SUITE M | ||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724016204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709103757 | ||||||||
| FaxNumber: | 8709104999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | A1309120 | AR | N | Behavioral Health & Social Service Providers | Counselor | 373H00000X | N | Nursing Service Related Providers | Day Training/Habilitation Specialist | 101YP2500X | P1610149 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.