Provider Demographics
NPI:1114591872
Name:RUSSELL, CAISIE MADISON
Entity Type:Individual
Prefix:
First Name:CAISIE
Middle Name:MADISON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 W CLAIBORNE RD APT 303
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3449
Mailing Address - Country:US
Mailing Address - Phone:443-306-6162
Mailing Address - Fax:
Practice Address - Street 1:111 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5996
Practice Address - Country:US
Practice Address - Phone:443-406-3234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2415101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)