Provider Demographics
NPI:1578648598
Name:RUSS, SUSANA (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4023
Mailing Address - Country:US
Mailing Address - Phone:530-662-2211
Mailing Address - Fax:530-662-4315
Practice Address - Street 1:455 1ST ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4023
Practice Address - Country:US
Practice Address - Phone:530-662-2211
Practice Address - Fax:530-662-4315
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS191151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10019Medicaid