Provider Demographics
NPI:1295366268
Name:GOVERNALE, RUSSELL SALVATORE (LMSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:SALVATORE
Last Name:GOVERNALE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-2043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:731 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2631
Practice Address - Country:US
Practice Address - Phone:718-822-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0447611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical