Healthcare Provider Details

I. General information

NPI: 1306376124
Provider Name (Legal Business Name): MICHAEL RUSS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/21/2022
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S WASHINGTON ST
MARION IN
46952-3867
US

IV. Provider business mailing address

101 S WASHINGTON ST
MARION IN
46952-3867
US

V. Phone/Fax

Practice location:
  • Phone: 765-662-9971
  • Fax:
Mailing address:
  • Phone: 765-662-9971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34009434A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: