Provider Demographics
NPI:1508321423
Name:RUSSELL, MARY (MSW, LADACII)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSW, LADACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MCCOWAT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-5279
Mailing Address - Country:US
Mailing Address - Phone:731-427-7238
Mailing Address - Fax:731-423-3811
Practice Address - Street 1:110 MCCOWAT ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-5279
Practice Address - Country:US
Practice Address - Phone:731-427-7238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDC0000000502101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)