Provider Demographics
NPI:1295266674
Name:RUSSELL, THERESA (LCSW)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N FEDERAL HWY
Mailing Address - Street 2:715
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-4171
Mailing Address - Country:US
Mailing Address - Phone:631-793-1365
Mailing Address - Fax:
Practice Address - Street 1:350 N FEDERAL HWY
Practice Address - Street 2:715
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-4171
Practice Address - Country:US
Practice Address - Phone:631-793-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW121811041C0700X
NYR053958-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical