Provider Demographics
NPI:1245380781
Name:RUSSELL, DIANE GAIL (MSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:GAIL
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25869 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4997
Mailing Address - Country:US
Mailing Address - Phone:586-773-6020
Mailing Address - Fax:586-773-6093
Practice Address - Street 1:25869 KELLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4997
Practice Address - Country:US
Practice Address - Phone:586-773-6020
Practice Address - Fax:586-773-6093
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010666571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N99040003Medicare ID - Type Unspecified