Provider Demographics
NPI:1578577631
Name:RUSSELL, JULIE BANNER (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JULIE
Middle Name:BANNER
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 381
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NH
Mailing Address - Zip Code:03031-0381
Mailing Address - Country:US
Mailing Address - Phone:978-952-0150
Mailing Address - Fax:978-952-6322
Practice Address - Street 1:442 KING ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1251
Practice Address - Country:US
Practice Address - Phone:978-952-0150
Practice Address - Fax:978-952-6322
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10161841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA773415OtherTUFTS HEALTH PLAN
MAP05767OtherBCBSMA
MA007162OtherVALUE OPTIONS
MA62-01666OtherUNITED BEHAVIORAL HEALTH
MAP23506Medicare ID - Type Unspecified