Provider Demographics
NPI:1417156795
Name:RUSSELL, LESLIE L (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 BECKETT DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3300
Mailing Address - Country:US
Mailing Address - Phone:803-731-4907
Mailing Address - Fax:
Practice Address - Street 1:514 S DARGAN ST STE H
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2552
Practice Address - Country:US
Practice Address - Phone:843-292-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0071521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical