Provider Demographics
NPI:1831267699
Name:BAILIFF, RUSSELL TEAL (LCSW)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:TEAL
Last Name:BAILIFF
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:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-0726
Mailing Address - Country:US
Mailing Address - Phone:903-312-7246
Mailing Address - Fax:
Practice Address - Street 1:716 LINUS LN
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-6626
Practice Address - Country:US
Practice Address - Phone:903-312-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX292641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0638405-04Medicaid
TX0638405-01Medicaid
TX0013EXOtherBLUE CROSS BLUE SHIELD
TX0638405-01Medicaid