Provider Demographics
NPI:1043415276
Name:RUSSELL, MONIQUE CLAUDETTE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:CLAUDETTE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:CLAUDETTE
Other - Last Name:RUSSELL-BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:340 TREELINE PARK APT 722
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1840
Mailing Address - Country:US
Mailing Address - Phone:917-971-3321
Mailing Address - Fax:
Practice Address - Street 1:4203 WOODCOCK DR STE 216
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1312
Practice Address - Country:US
Practice Address - Phone:210-564-9116
Practice Address - Fax:210-564-9087
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052482104100000X
TX616361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker