| Doctor Name: | MICHELLE DAWN RUSSUM |
| NPI Number: | 1134457187 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MA, LPC |
| License Number: | 2004022009 |
| Business Practice Address: | 3797 Highway 54 Suite 120 Osage Beach, MO - 650652186 |
| Business Phone Number: | 5733483010 |
| Business Fax Number: | |
| Mailing Address: | 775 Sunrise Acres Point, SUMRISE BEACH |
| State: | MO |
| Postal Code: | 65097 |
| Phone Number: | 5735521416 |
| Fax Number: | |
| NPI Enumeration Date: | 12/03/2009 |
| NPI Last Update Date: | 02/22/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YP2500X |
| License Number: | 2004022009 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Professional |
| Taxonomy Definition: | |