Healthcare Provider Details

I. General information

NPI: 1649394008
Provider Name (Legal Business Name): RALPH J RUSSELL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 1 BOX 67
HARLEM MT
59526-9705
US

IV. Provider business mailing address

319 9TH AVE
HAVRE MT
59501-3754
US

V. Phone/Fax

Practice location:
  • Phone: 406-353-3100
  • Fax: 406-353-3229
Mailing address:
  • Phone: 406-353-3162
  • Fax: 406-353-3308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number175 LCSW
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: