MEDICARE: NANCY RAE RUSSELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW6791	FL

General Provider Information

NPI Number	:	1003942962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY RAE RUSSELL LCSW

Provider Business Mailing Address
First Line	:	6739 1ST AVE S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33707-1307
Country	:	US
Telephone Number	:	727-341-1000
Fax Number	:	727-341-1000

Provider Business Practice Location Address
First Line	:	6737 1ST AVE S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33707-1307
Country	:	US
Telephone Number	:	727-341-1000
Fax Number	:	727-341-1000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	02/22/2012

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