Provider Demographics
NPI:1417609629
Name:RUSS, INGER LUCILLE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:INGER
Middle Name:LUCILLE
Last Name:RUSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10616 SAN SIMEON LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-6835
Mailing Address - Country:US
Mailing Address - Phone:817-996-5438
Mailing Address - Fax:
Practice Address - Street 1:10616 SAN SIMEON LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-6835
Practice Address - Country:US
Practice Address - Phone:817-996-5438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX265711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical