Provider Demographics
NPI:1740732338
Name:RUSSELL, SCOTT I (MSW)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:I
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 VINE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-1612
Mailing Address - Country:US
Mailing Address - Phone:323-769-6100
Mailing Address - Fax:
Practice Address - Street 1:1224 VINE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1612
Practice Address - Country:US
Practice Address - Phone:323-769-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-29
Last Update Date:2019-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW71593101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health