Provider Demographics
NPI:1801209267
Name:RUSSELL, BETTY GRACE (LCSW)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:GRACE
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 1:901 N JONES BLVD UNIT 213
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-1603
Mailing Address - Country:US
Mailing Address - Phone:702-626-3230
Mailing Address - Fax:
Practice Address - Street 1:901 N JONES BLVD UNIT 213
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-1603
Practice Address - Country:US
Practice Address - Phone:702-626-3230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-12165101YM0800X
NV7437-C101YM0800X
NV6120-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health