Healthcare Provider Details

I. General information

NPI: 1093344681
Provider Name (Legal Business Name): NATHANAEL WILLIAM RUSSELL LMSW, QMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2837 WALNUT ST
PORT HURON MI
48060-2162
US

IV. Provider business mailing address

2837 WALNUT ST
PORT HURON MI
48060-2162
US

V. Phone/Fax

Practice location:
  • Phone: 810-689-4547
  • Fax:
Mailing address:
  • Phone: 810-858-1759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801106998
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801114888
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: