Provider Demographics
NPI:1427002708
Name:RUSSELL, CONSTANCE ELAINE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:ELAINE
Last Name:RUSSELL
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 1:6400 MANATEE AVE W
Mailing Address - Street 2:SUITE F
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-2378
Mailing Address - Country:US
Mailing Address - Phone:941-795-2228
Mailing Address - Fax:
Practice Address - Street 1:6400 MANATEE AVE W
Practice Address - Street 2:SUITE F
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-2378
Practice Address - Country:US
Practice Address - Phone:941-795-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL003241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ2264Medicare UPIN