Provider Demographics
NPI:1366627473
Name:RUSSELL, SANDRA JUNE (CMSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:JUNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CMSW
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:DUCHARME
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CMSW
Mailing Address - Street 1:604 S WALL ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-3797
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:604 S WALL ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3797
Practice Address - Country:US
Practice Address - Phone:931-684-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000004569OtherCMSW