Provider Demographics
NPI:1821332131
Name:RUSSELL RICCI, LAURA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:RUSSELL RICCI
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 1:1715 MARION WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:14425-9737
Mailing Address - Country:US
Mailing Address - Phone:585-297-4872
Mailing Address - Fax:
Practice Address - Street 1:1715 MARION WAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NY
Practice Address - Zip Code:14425-9737
Practice Address - Country:US
Practice Address - Phone:585-297-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087168-1101Y00000X
NY0857911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor