Healthcare Provider Details

I. General information

NPI: 1356458822
Provider Name (Legal Business Name): SHEILA A RUSSELL LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 RESERVOIR AVE
REHOBOTH MA
02769
US

IV. Provider business mailing address

34 RESERVOIR AVE
REHOBOTH MA
02769-2906
US

V. Phone/Fax

Practice location:
  • Phone: 401-556-9174
  • Fax:
Mailing address:
  • Phone: 401-556-9174
  • Fax: 401-455-6222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW01192
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: