Provider Demographics
NPI:1245376193
Name:HART, RUSSELL (LICSW)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:HART
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MARIAN RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-2125
Mailing Address - Country:US
Mailing Address - Phone:978-692-4032
Mailing Address - Fax:978-929-0861
Practice Address - Street 1:319 LITTLETON RD
Practice Address - Street 2:SUITE 108
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-4126
Practice Address - Country:US
Practice Address - Phone:978-692-4032
Practice Address - Fax:978-929-0861
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105649101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA105649OtherSOCIAL WORK LICENSE