Provider Demographics
NPI:1437485950
Name:RUSSELL, GWENDOLYN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:
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 1:655 COLFAX ST
Mailing Address - Street 2:EDISON HIGH SCHOOL BASED HEALTH CENTER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-3113
Mailing Address - Country:US
Mailing Address - Phone:585-324-9750
Mailing Address - Fax:585-277-0170
Practice Address - Street 1:655 COLFAX ST
Practice Address - Street 2:EDISON HIGH SCHOOL BASED HEALTH CENTER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-3113
Practice Address - Country:US
Practice Address - Phone:585-324-9750
Practice Address - Fax:585-277-0170
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071091-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical