Provider Demographics
NPI:1346614724
Name:RUSS, MALAIKA DEANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:MALAIKA
Middle Name:DEANDRA
Last Name:RUSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 WOODLAND HILLS CT
Mailing Address - Street 2:
Mailing Address - City:SEMMES
Mailing Address - State:AL
Mailing Address - Zip Code:36575-7445
Mailing Address - Country:US
Mailing Address - Phone:678-763-5869
Mailing Address - Fax:
Practice Address - Street 1:1805 WOODLAND HILLS CT
Practice Address - Street 2:
Practice Address - City:SEMMES
Practice Address - State:AL
Practice Address - Zip Code:36575-7445
Practice Address - Country:US
Practice Address - Phone:678-763-5869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-22
Last Update Date:2015-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3638C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical