Provider Demographics
NPI:1578593026
Name:FAST, RUSSELL R (LICSW)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:R
Last Name:FAST
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2904
Mailing Address - Country:US
Mailing Address - Phone:701-483-1000
Mailing Address - Fax:701-483-1001
Practice Address - Street 1:1679 6TH AVE W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2904
Practice Address - Country:US
Practice Address - Phone:701-483-1000
Practice Address - Fax:701-483-1001
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND22121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455118Medicaid
ND12990OtherBC/BS PIN
NDN12990Medicare PIN
ND12990OtherBC/BS PIN