Healthcare Provider Details

I. General information

NPI: 1265396139
Provider Name (Legal Business Name): IMANI RUSSELL LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7310 WOODWARD AVE STE 601
DETROIT MI
48202-3165
US

IV. Provider business mailing address

680 HAZELWOOD ST APT 4
DETROIT MI
48202-1716
US

V. Phone/Fax

Practice location:
  • Phone: 313-896-1444
  • Fax: 313-896-1466
Mailing address:
  • Phone: 260-508-9533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851118559
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: