Provider Demographics
NPI:1770198525
Name:RUSSELL, YVONNE C (LSW)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:C
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N CHESTNUT ST.
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266
Mailing Address - Country:US
Mailing Address - Phone:330-296-5552
Mailing Address - Fax:330-296-6126
Practice Address - Street 1:771 N. FREEDOM ST.
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266
Practice Address - Country:US
Practice Address - Phone:330-296-5552
Practice Address - Fax:330-296-6126
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2308890104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0418609Medicaid