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General NPI Number Information
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NPI Number | 1093344681
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Entity Type | Individual
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Provider Name | NATHANAEL WILLIAM RUSSELL LMSW, QMHP
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Gender | Male
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Dates
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Enumeration Date | 04/06/2020
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Last Update Date | 01/29/2026
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Provider Practice Location Address
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Address Line | 2837 WALNUT ST
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City | PORT HURON
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State | MI
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Zip | 48060-2162
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Country | US
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Telephone | 810-689-4547
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Fax |
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Provider Business Mailing Address
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Address Line | 2837 WALNUT ST
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City | PORT HURON
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State | MI
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Zip | 48060-2162
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Country | US
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Telephone | 810-858-1759
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801106998
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801114888
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License Number State | MI
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