Healthcare Provider Details

I. General information

NPI: 1376934869
Provider Name (Legal Business Name): LINDA RUSSELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 S HIGHWAY 27 STE 4
SOMERSET KY
42501-3124
US

IV. Provider business mailing address

276 GATE RD
RUSSELL SPRINGS KY
42642-9540
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-1815
  • Fax: 606-451-1631
Mailing address:
  • Phone: 606-875-4210
  • Fax: 606-451-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number252558
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4626
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: