Provider Demographics
NPI:1841539269
Name:RUSSELL, KATHLEEN M (LMSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 PRIVATE ROAD 5130
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75979-6734
Mailing Address - Country:US
Mailing Address - Phone:409-382-3120
Mailing Address - Fax:
Practice Address - Street 1:139 WEST LAMAR STREET
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951
Practice Address - Country:US
Practice Address - Phone:409-384-6829
Practice Address - Fax:409-384-4770
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53914104100000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator