Individual
CONNIE RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CSAC
Contact information
Practice address
712 55TH ST, KENOSHA, WI 53140-6506
(262) 842-0538
Mailing address
5407 8TH AVE, KENOSHA, WI 53140-3715
(262) 657-7188
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
1915-132
WI
Other
Enumeration date
07/10/2013
Last updated
07/11/2013
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