Provider Demographics
NPI:1356393938
Name:RUSSELL, NANCY (CSW)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COLLINS AVE
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-4804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 CENTRAL AVENUE
Practice Address - Street 2:CLEARVIEW CENTER
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1708
Practice Address - Country:US
Practice Address - Phone:518-435-9931
Practice Address - Fax:518-459-3715
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069215104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00069215Medicaid
NY00069215Medicaid