Healthcare Provider Details

I. General information

NPI: 1588765614
Provider Name (Legal Business Name): LARRY WAYNE RUSSELL LSW MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 PARCOAL RD
WEBSTER SPRINGS WV
26288-9767
US

IV. Provider business mailing address

81 FRONT ST
RICHWOOD WV
26261-1307
US

V. Phone/Fax

Practice location:
  • Phone: 304-847-5425
  • Fax: 304-847-5422
Mailing address:
  • Phone: 304-847-5425
  • Fax: 304-847-5422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberAP00940954
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: