Provider Demographics
NPI:1558648295
Name:RUSSELL, LACEY J (LMSW)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:J
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 1:468 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BAILEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66404-8484
Mailing Address - Country:US
Mailing Address - Phone:785-289-6585
Mailing Address - Fax:
Practice Address - Street 1:909 S 2ND ST
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2774
Practice Address - Country:US
Practice Address - Phone:785-742-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9213104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker