Healthcare Provider Details

I. General information

NPI: 1063567139
Provider Name (Legal Business Name): MERCY BURTON RUSSELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MERCY RUSSELL HYDE LCSW

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 SPRUCE ST STE C&D
ESPANOLA NM
87532-3455
US

IV. Provider business mailing address

835 SPRUCE ST STE C&D
ESPANOLA NM
87532-3455
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-7400
  • Fax: 505-443-8310
Mailing address:
  • Phone: 505-747-7400
  • Fax: 505-443-8310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number89-0000212
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19550
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-0022
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: