Provider Demographics
NPI:1760581482
Name:RUSSELL, HEATHER ANN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MERRIAM AVE
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-3158
Mailing Address - Country:US
Mailing Address - Phone:978-860-5172
Mailing Address - Fax:
Practice Address - Street 1:59 MERRIAM AVE
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-3158
Practice Address - Country:US
Practice Address - Phone:978-860-5172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASW 114235-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical