Provider Demographics
NPI:1265093892
Name:RUSSELL, KYLIE (LMSW)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-6067
Mailing Address - Country:US
Mailing Address - Phone:515-494-4245
Mailing Address - Fax:
Practice Address - Street 1:403 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-2840
Practice Address - Country:US
Practice Address - Phone:319-289-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA095226104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker