Provider Demographics
NPI:1649394008
Name:RUSSELL, RALPH J (LCSW)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-3754
Mailing Address - Country:US
Mailing Address - Phone:406-353-3162
Mailing Address - Fax:406-353-3308
Practice Address - Street 1:RR 1 BOX 67
Practice Address - Street 2:
Practice Address - City:HARLEM
Practice Address - State:MT
Practice Address - Zip Code:59526-9705
Practice Address - Country:US
Practice Address - Phone:406-353-3100
Practice Address - Fax:406-353-3229
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT175 LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT175 LCSWOtherLICENSE
MT8HZ61BMedicare PIN