Provider Demographics
NPI:1609018779
Name:RUSSELL, TRACEY (LMSW)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
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 1:210 MANOR ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-1936
Mailing Address - Country:US
Mailing Address - Phone:870-739-6818
Mailing Address - Fax:870-739-1970
Practice Address - Street 1:1825 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-3409
Practice Address - Country:US
Practice Address - Phone:870-630-2328
Practice Address - Fax:870-630-2348
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical