Provider Demographics
NPI:1962813253
Name:VOLLMER, RUSSELL LYNN (LCSW)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LYNN
Last Name:VOLLMER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2672 N 3100 W
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-6519
Mailing Address - Country:US
Mailing Address - Phone:208-637-9813
Mailing Address - Fax:
Practice Address - Street 1:215 E 50 S STE 5
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-2300
Practice Address - Country:US
Practice Address - Phone:208-766-2365
Practice Address - Fax:208-766-2364
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT286822-35011041C0700X, 104100000X
IDLCSW-369111041C0700X
IDLSW-286231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical