Healthcare Provider Details

I. General information

NPI: 1790273647
Provider Name (Legal Business Name): SHANNON D RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 MAIN ST
EAST HARTFORD CT
06108-1684
US

IV. Provider business mailing address

1406 MAIN ST
EAST HARTFORD CT
06108-1684
US

V. Phone/Fax

Practice location:
  • Phone: 860-249-0975
  • Fax:
Mailing address:
  • Phone: 860-249-0975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6372
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: