Provider Demographics
NPI:1417463621
Name:RUSSELL, HEATHER LYNN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-5302
Mailing Address - Country:US
Mailing Address - Phone:308-293-4380
Mailing Address - Fax:308-224-3711
Practice Address - Street 1:2002 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68847-5302
Practice Address - Country:US
Practice Address - Phone:308-627-4743
Practice Address - Fax:308-224-3711
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-26
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE113571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical