Provider Demographics
NPI:1770835811
Name:RUSSELL, TAMMY MASON (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:MASON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 SHEFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1981
Mailing Address - Country:US
Mailing Address - Phone:757-825-5720
Mailing Address - Fax:
Practice Address - Street 1:835 SHEFFIELD ST
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1981
Practice Address - Country:US
Practice Address - Phone:757-825-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-14
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040037211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical