Provider Demographics
NPI:1295944254
Name:RUSSELL, OLIVER (LCSW-C)
Entity type:Individual
Prefix:
First Name:OLIVER
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W TAYLOR RUN PKWY
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4932
Mailing Address - Country:US
Mailing Address - Phone:703-795-4920
Mailing Address - Fax:
Practice Address - Street 1:1001 LAWRENCE ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-3513
Practice Address - Country:US
Practice Address - Phone:202-635-5990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD107491041C0700X
DCLC30007961041C0700X
VA09040052171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCLC30007976Medicaid
MDLCSW-C10749Medicaid
VA0904005217Medicaid
DCLC30007976Medicaid