Provider Demographics
NPI:1639488265
Name:RUSSELL, RONDA
Entity Type:Individual
Prefix:
First Name:RONDA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 LAKE SHORE DR W
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:14048-1437
Mailing Address - Country:US
Mailing Address - Phone:716-366-6858
Mailing Address - Fax:
Practice Address - Street 1:186 LAKE SHORE DR W
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-1437
Practice Address - Country:US
Practice Address - Phone:716-366-6858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0741501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical