MEDICARE: MRS. MARY BETH RUSSO BLACKWELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW18791	FL

General Provider Information

NPI Number	:	1063731263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY BETH RUSSO BLACKWELL LCSW

Provider Business Mailing Address
First Line	:	220 ARLINGTON WAY
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-8164
Country	:	US
Telephone Number	:	386-882-7251
Fax Number	:

Provider Business Practice Location Address
First Line	:	220 ARLINGTON WAY
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-8164
Country	:	US
Telephone Number	:	386-882-7251
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2010
Last Update Date	:	03/03/2025

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