Provider Demographics
NPI:1619015179
Name:BUSKIRK, RUSSEL DAMIEN (LCSW, LCDP)
Entity Type:Individual
Prefix:MR
First Name:RUSSEL
Middle Name:DAMIEN
Last Name:BUSKIRK
Suffix:
Gender:M
Credentials:LCSW, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ROCKFORD RD APT A2
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1006
Mailing Address - Country:US
Mailing Address - Phone:302-220-6825
Mailing Address - Fax:
Practice Address - Street 1:410 FOULK RD
Practice Address - Street 2:SUITE 105
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3820
Practice Address - Country:US
Practice Address - Phone:302-762-2285
Practice Address - Fax:302-762-2286
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECD-0000006101YA0400X
DEQ1-00006971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE2006603272OtherBUSINESS LICENSE