Provider Demographics
NPI:1437650025
Name:RUSSELL, MONIQUE
Entity Type:Individual
Prefix:MRS
First Name:MONIQUE
Middle Name:
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 1:333 HEMPSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:MALVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11565-1254
Mailing Address - Country:US
Mailing Address - Phone:585-333-0299
Mailing Address - Fax:
Practice Address - Street 1:333 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-1254
Practice Address - Country:US
Practice Address - Phone:585-333-0299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
109638104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator