Provider Demographics
NPI:1336897404
Name:RUSSWINKEL, BLAKE (LSW)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:RUSSWINKEL
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1651 CHEROKEE RD APT 3B
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-4955
Mailing Address - Country:US
Mailing Address - Phone:217-473-9889
Mailing Address - Fax:
Practice Address - Street 1:2014 VANDALIA ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4848
Practice Address - Country:US
Practice Address - Phone:618-345-9536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-04-27
Deactivation Date:2022-03-16
Deactivation Code:
Reactivation Date:2022-04-27
Provider Licenses
StateLicense IDTaxonomies
IL150104739104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker