Healthcare Provider Details

I. General information

NPI: 1932142197
Provider Name (Legal Business Name): CATHERINE A RUSSELL MSW, LCSW, DCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA CLINIC 21425 SPRING
UNION GROVE WI
53182
US

IV. Provider business mailing address

23423 CHURCH RD
KANSASVILLE WI
53139-9726
US

V. Phone/Fax

Practice location:
  • Phone: 262-878-7011
  • Fax:
Mailing address:
  • Phone: 262-878-2638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2857-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: