Provider Demographics
NPI:1598449498
Name:RUSSELL, KAMRYN M (LCSW)
Entity Type:Individual
Prefix:
First Name:KAMRYN
Middle Name:M
Last Name:RUSSELL
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 1:115 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2214
Mailing Address - Country:US
Mailing Address - Phone:716-397-6770
Mailing Address - Fax:
Practice Address - Street 1:115 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-2214
Practice Address - Country:US
Practice Address - Phone:716-397-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical