Healthcare Provider Details

I. General information

NPI: 1407961022
Provider Name (Legal Business Name): JOHN RUSSUM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21444 CARMEAN WAY
GEORGETOWN DE
19947-4572
US

IV. Provider business mailing address

21444 CARMEAN WAY
GEORGETOWN DE
19947-4572
US

V. Phone/Fax

Practice location:
  • Phone: 302-855-1233
  • Fax:
Mailing address:
  • Phone: 302-855-1233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ10000855
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: