Provider Demographics
NPI:1407961022
Name:RUSSUM, JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUSSUM
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 1:725 HORSEPOND RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-7232
Mailing Address - Country:US
Mailing Address - Phone:302-744-7688
Mailing Address - Fax:302-735-3856
Practice Address - Street 1:725 HORSEPOND RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-7232
Practice Address - Country:US
Practice Address - Phone:302-744-7688
Practice Address - Fax:302-735-3856
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEQ100008551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEQ10000855OtherCLINICAL LICENSE