Healthcare Provider Details

I. General information

NPI: 1477097392
Provider Name (Legal Business Name): MARK RUSSELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 WILLOWBROOK DR
SALTILLO MS
38866-6896
US

IV. Provider business mailing address

131 WILLOWBROOK DR
SALTILLO MS
38866-6896
US

V. Phone/Fax

Practice location:
  • Phone: 662-401-6457
  • Fax: 662-346-5438
Mailing address:
  • Phone: 662-401-6457
  • Fax: 662-346-5438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC9259
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: