Provider Demographics
NPI:1477873925
Name:RUSSELL, KATHLEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 BAILEY CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1321
Mailing Address - Country:US
Mailing Address - Phone:631-345-3267
Mailing Address - Fax:
Practice Address - Street 1:27 BAILEY CT
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1321
Practice Address - Country:US
Practice Address - Phone:631-345-3267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072586-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical