Provider Demographics
NPI:1407078603
Name:RUSSELL, BRIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4823 N ROYAL ATLANTA DR
Mailing Address - Street 2:C
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4823 N ROYAL ATLANTA DR
Practice Address - Street 2:C
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3806
Practice Address - Country:US
Practice Address - Phone:770-939-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX558151041C0700X
GACSW0043911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical