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General NPI Number Information
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NPI Number | 1982999884
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Entity Type | Individual
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Provider Name | JUDITH RUSSELL LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/20/2011
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Last Update Date | 06/20/2011
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Provider Practice Location Address
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Address Line | 47 1ST ST
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City | REDLANDS
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State | CA
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Zip | 92373-4601
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Country | US
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Telephone | 909-633-9683
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5276
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City | CRESTLINE
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State | CA
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Zip | 92325-5276
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Country | US
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Telephone | 909-633-9683
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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 | 25716
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 25716
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License Number State | CA
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