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General NPI Number Information
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NPI Number | 1336244763
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Entity Type | Individual
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Provider Name | KELLY GRAVINO RUSSELL LICSW
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Gender | Female
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 06/29/2020
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Provider Practice Location Address
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Address Line | 16 BUSH HILL RD
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City | IPSWICH
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State | MA
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Zip | 01938-1642
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Country | US
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Telephone | 978-810-8397
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Fax |
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Provider Business Mailing Address
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Address Line | 16 BUSH HILL RD
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City | IPSWICH
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State | MA
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Zip | 01938-1642
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Country | US
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Telephone | 978-810-8397
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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 | 110340
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License Number State | MA
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