Provider Demographics
NPI:1093940140
Name:RUSSELL, MARIE DAWN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:DAWN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:74 BUNNER ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-3357
Mailing Address - Country:US
Mailing Address - Phone:315-343-8162
Mailing Address - Fax:
Practice Address - Street 1:74 BUNNER ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3357
Practice Address - Country:US
Practice Address - Phone:315-343-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074588-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical