MEDICARE: MERCY BURTON 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	89-0000212	VT
2	1041C0700X	Clinical Social Worker	19550	AZ
3	1041C0700X	Clinical Social Worker	SWB-2025-0022	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	821-8223	OTHER	VT	VERMONT BCBS PIN
2	89-0000212	OTHER	VT	VERMONT LCSW

General Provider Information

NPI Number	:	1063567139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERCY BURTON RUSSELL LCSW

Provider Business Mailing Address
First Line	:	835 SPRUCE ST STE C&D
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-3455
Country	:	US
Telephone Number	:	505-747-7400
Fax Number	:	505-443-8310

Provider Business Practice Location Address
First Line	:	835 SPRUCE ST STE C&D
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-3455
Country	:	US
Telephone Number	:	505-747-7400
Fax Number	:	505-443-8310

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

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	06/20/2025

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Directions to “ MERCY BURTON RUSSELL LCSW” Practice Location

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