MEDICARE: LORI RUSSELL-SIEMER LLC

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

General Provider Information

NPI Number	:	1588286504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LORI RUSSELL-SIEMER LLC

Provider Business Mailing Address
First Line	:	1930 SANTA ANNA DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-5611
Country	:	US
Telephone Number	:	817-706-1728
Fax Number	:

Provider Business Practice Location Address
First Line	:	1703 PEYCO DR N STE L
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-6701
Country	:	US
Telephone Number	:	817-854-4991
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LORI RUSSELL-SIEMER
Credential	:	LCSW
Telephone Number	:	817-706-1728

Provider Enumeration Date	:	05/13/2020
Last Update Date	:	05/13/2020

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