Healthcare Provider Details

I. General information

NPI: 1437650025
Provider Name (Legal Business Name): MRS. MONIQUE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 HAMPTON PARK BLVD STE Q
CAPITOL HEIGHTS MD
20743-3862
US

IV. Provider business mailing address

75 WASHINGTON ST UNIT 516
FAIRBURN GA
30213-3605
US

V. Phone/Fax

Practice location:
  • Phone: 585-333-0299
  • Fax:
Mailing address:
  • Phone: 585-333-0299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109638
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009661
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29801
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number099073
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: