Provider Demographics
NPI:1093059974
Name:RUSSELL, STEPHEN TREY (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:TREY
Last Name:RUSSELL
Suffix:
Gender:M
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 100
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75461-0100
Mailing Address - Country:US
Mailing Address - Phone:903-783-1282
Mailing Address - Fax:903-783-1251
Practice Address - Street 1:1849 LAMAR AVE STE 120
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-1463
Practice Address - Country:US
Practice Address - Phone:903-715-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352276504Medicaid