Provider Demographics
NPI:1861833428
Name:RUSSELL-ANDERSEN, JOYCE (LCSW)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:
Last Name:RUSSELL-ANDERSEN
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 1:3911 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5110
Mailing Address - Country:US
Mailing Address - Phone:718-948-3232
Mailing Address - Fax:718-966-6605
Practice Address - Street 1:3911 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5110
Practice Address - Country:US
Practice Address - Phone:718-948-3232
Practice Address - Fax:718-966-6605
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072444-1101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07209Medicaid