Provider Demographics
NPI:1700892189
Name:RUSSELL, MAUREEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 N 1ST ST
Mailing Address - Street 2:#119
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0563
Mailing Address - Country:US
Mailing Address - Phone:559-226-5324
Mailing Address - Fax:559-226-5324
Practice Address - Street 1:4747 N 1ST ST
Practice Address - Street 2:#119
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-0563
Practice Address - Country:US
Practice Address - Phone:559-226-5324
Practice Address - Fax:559-226-5324
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 114121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA73-1662251OtherEIN NUMBER