Healthcare Provider Details

I. General information

NPI: 1346557543
Provider Name (Legal Business Name): RUSSELL JEREMY GWILLIAM MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 FRONT ST
WORCESTER MA
01608-1733
US

IV. Provider business mailing address

12 PINEVIEW TRL
AUBURN MA
01501-2120
US

V. Phone/Fax

Practice location:
  • Phone: 508-753-0321
  • Fax:
Mailing address:
  • Phone: 508-864-0839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1745
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: