| Doctor Name: | MRS. PANOLA E. RUSSELL |
| NPI Number: | 1336479542 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LCPC CCBT LCAC |
| License Number: | 87001334A |
| Business Practice Address: | 855 Burnham Dr Apt F University Park, IL - 604843042 |
| Business Phone Number: | 7085347559 |
| Business Fax Number: | |
| Mailing Address: | 855 Burnham Dr Apt F, UNIVERSITY PARK |
| State: | IL |
| Postal Code: | 604843042 |
| Phone Number: | 7085347559 |
| Fax Number: | |
| NPI Enumeration Date: | 01/11/2010 |
| NPI Last Update Date: | 05/25/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 87001334A |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | IN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |