Provider Demographics
NPI:1063012649
Name:RUSSELL, KATHLEEN (CSWA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4931 SW 76TH AVE # 128
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1805
Mailing Address - Country:US
Mailing Address - Phone:503-572-9340
Mailing Address - Fax:
Practice Address - Street 1:7700 SW GARDEN HOME RD APT 23
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-7496
Practice Address - Country:US
Practice Address - Phone:503-572-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA50501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical