Provider Demographics
NPI:1962852384
Name:RUSSELL, MARISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:R
Other - Last Name:CAPULLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3044 ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-3073
Mailing Address - Country:US
Mailing Address - Phone:518-886-5800
Mailing Address - Fax:518-886-5805
Practice Address - Street 1:3044 ROUTE 50
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-3073
Practice Address - Country:US
Practice Address - Phone:518-886-5800
Practice Address - Fax:518-886-8505
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0847591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical