Provider Demographics
NPI:1841309838
Name:RUSSELL, SUZANNE JENKINS (LCSW CCM)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:JENKINS
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW CCM
Other - Prefix:MRS
Other - First Name:SUZANNE
Other - Middle Name:RUSSELL
Other - Last Name:THORNBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW CCM
Mailing Address - Street 1:11400 RANCHITOS RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2394
Mailing Address - Country:US
Mailing Address - Phone:505-379-3703
Mailing Address - Fax:505-639-5780
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:505-379-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-066181041C0700X
NM4247900171M00000X
IDLCSW-420251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15226379Medicaid