Provider Demographics
NPI:1477097392
Name:RUSSELL, MARK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-4853
Mailing Address - Country:US
Mailing Address - Phone:662-840-8020
Mailing Address - Fax:662-840-8021
Practice Address - Street 1:302 S SPRING ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-4853
Practice Address - Country:US
Practice Address - Phone:662-840-8020
Practice Address - Fax:662-840-8021
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker