Provider Demographics
NPI:1891821963
Name:RUSSIN, ELLEN RUSSIN J (LCSW)
Entity Type:Individual
Prefix:
First Name:ELLEN RUSSIN
Middle Name:J
Last Name:RUSSIN
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 1:667 LYTTON AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-1335
Mailing Address - Country:US
Mailing Address - Phone:650-566-0061
Mailing Address - Fax:650-473-6801
Practice Address - Street 1:667 LYTTON AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-1335
Practice Address - Country:US
Practice Address - Phone:650-566-0061
Practice Address - Fax:650-473-6801
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS69351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical