Provider Demographics
NPI:1093932469
Name:FUSSELL, SALLY GAINES (LCSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:GAINES
Last Name:FUSSELL
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 1:6601 NORTHEAST DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-2126
Mailing Address - Country:US
Mailing Address - Phone:512-971-7901
Mailing Address - Fax:
Practice Address - Street 1:6601 NORTHEAST DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2126
Practice Address - Country:US
Practice Address - Phone:512-971-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158286801Medicaid