Provider Demographics
NPI:1073860847
Name:RUSSELL, KAILEEN (LICSW)
Entity type:Individual
Prefix:MRS
First Name:KAILEEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:KAILEEN
Other - Middle Name:
Other - Last Name:EGGLESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:41 RUGGLES ST
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01080-1143
Mailing Address - Country:US
Mailing Address - Phone:413-427-6676
Mailing Address - Fax:
Practice Address - Street 1:264 N MAIN ST STE 14
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1837
Practice Address - Country:US
Practice Address - Phone:413-564-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical