Provider Demographics
NPI:1710641634
Name:RUSSMAN, BRIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RUSSMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 INDEPENDENCE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6102
Mailing Address - Country:US
Mailing Address - Phone:772-577-1883
Mailing Address - Fax:
Practice Address - Street 1:1404 INDEPENDENCE LN
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6102
Practice Address - Country:US
Practice Address - Phone:772-577-1883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW123661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical