Provider Demographics
NPI:1023206034
Name:RUSSALESI, SANDRA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:RUSSALESI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3304
Mailing Address - Street 2:
Mailing Address - City:IDAHO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80452-3304
Mailing Address - Country:US
Mailing Address - Phone:303-567-0678
Mailing Address - Fax:303-567-9723
Practice Address - Street 1:1800 COLORADO BLVD.
Practice Address - Street 2:
Practice Address - City:IDAHO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80452-3304
Practice Address - Country:US
Practice Address - Phone:303-349-5114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO992689101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health