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General NPI Number Information
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NPI Number | 1134999600
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Entity Type | Individual
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Provider Name | RUSSELL FIELDS
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Gender | Male
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Dates
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Enumeration Date | 01/05/2024
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Last Update Date | 01/05/2024
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Provider Practice Location Address
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Address Line | 1500 N WESTWOOD BLVD
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-3318
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Country | US
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Telephone | 573-300-0138
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Fax |
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Provider Business Mailing Address
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Address Line | 273 SHELLY LN
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-7734
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Country | US
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Telephone | 573-300-0138
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 2023036364
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License Number State | MO
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