Provider Demographics
NPI:1346526969
Name:RUSSELL, DEBRA L (LCSWR)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1025
Mailing Address - Country:US
Mailing Address - Phone:716-308-0399
Mailing Address - Fax:
Practice Address - Street 1:768 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1025
Practice Address - Country:US
Practice Address - Phone:716-308-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR01773211041C0700X
NY6796859611041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool