Provider Demographics
NPI:1790273647
Name:RUSSELL, SHANNON D
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
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 1:1406 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1684
Mailing Address - Country:US
Mailing Address - Phone:860-249-0975
Mailing Address - Fax:
Practice Address - Street 1:1406 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-1684
Practice Address - Country:US
Practice Address - Phone:860-249-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT63721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical