MEDICARE: NATHANAEL WILLIAM RUSSELL LMSW, QMHP

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	6801106998	MI
2	1041C0700X	Clinical Social Worker
3	1041C0700X	Clinical Social Worker	6801114888	MI

General Provider Information

NPI Number	:	1093344681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHANAEL WILLIAM RUSSELL LMSW, QMHP

Provider Business Mailing Address
First Line	:	2837 WALNUT ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-2162
Country	:	US
Telephone Number	:	810-858-1759
Fax Number	:

Provider Business Practice Location Address
First Line	:	2837 WALNUT ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-2162
Country	:	US
Telephone Number	:	810-689-4547
Fax Number	:

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

Provider Enumeration Date	:	04/06/2020
Last Update Date	:	01/29/2026

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