Individual
BLAKE RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
9666 OLIVE BLVD STE 400, SAINT LOUIS, MO 63132-3025
(314) 252-0671
Mailing address
3956 THOLOZAN AVE, SAINT LOUIS, MO 63116-3633
(573) 645-0396
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
Primary
2018043939
MO
Other
Enumeration date
01/12/2021
Last updated
01/12/2021
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