Individual
LEAH AV RUSSACK-BAKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LADC
Contact information
Practice address
123 ELM ST, OLD SAYBROOK, CT 06475
(860) 395-1264
Mailing address
123 ELM ST, OLD SAYBROOK, CT 06475-4108
(860) 395-1264
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
03-973340
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1730336439
—
CT
Enumeration date
09/29/2010
Last updated
09/29/2010
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