Healthcare Provider Details

I. General information

NPI: 1841539269
Provider Name (Legal Business Name): KATHLEEN M RUSSELL LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 WEST LAMAR STREET
JASPER TX
75951
US

IV. Provider business mailing address

407 PRIVATE ROAD 5130
WOODVILLE TX
75979-6734
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-6829
  • Fax: 409-384-4770
Mailing address:
  • Phone: 409-382-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number53914
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number53914
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: