Provider Demographics
NPI:1457118655
Name:RUSSELL, CARISSA (LMSW, CSW-I, MED)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW, CSW-I, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-3636
Mailing Address - Country:US
Mailing Address - Phone:775-671-5728
Mailing Address - Fax:
Practice Address - Street 1:407 N WALSH ST
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89701-4268
Practice Address - Country:US
Practice Address - Phone:775-298-6386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11251-M104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker