1235550575 NPI number — CATHERINE LENORE RUSSELL MSW, LICSW

Table of content: CATHERINE LENORE RUSSELL MSW, LICSW (NPI 1235550575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235550575 NPI number — CATHERINE LENORE RUSSELL MSW, LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
CATHERINE
Provider Middle Name:
LENORE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235550575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1409 WILLOW ST STE 305
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55403-3289
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-325-1905
Provider Business Mailing Address Fax Number:
888-314-7340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 WILLOW ST
Provider Second Line Business Practice Location Address:
STE 305
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55403-3289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-325-1905
Provider Business Practice Location Address Fax Number:
888-314-7340
Provider Enumeration Date:
01/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  20480 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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