Provider Demographics
NPI:1265112858
Name:RUSSELL, DONNA MARIE (LCSW)
Entity type:Individual
Prefix:MISS
First Name:DONNA
Middle Name:MARIE
Last Name:RUSSELL
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 1:1814 DIXDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210-2126
Mailing Address - Country:US
Mailing Address - Phone:502-408-4969
Mailing Address - Fax:
Practice Address - Street 1:1814 DIXDALE AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210-2126
Practice Address - Country:US
Practice Address - Phone:502-408-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2578141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical