Provider Demographics
NPI:1083199251
Name:RUSSELL, OLIVIA B (LCSW)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:B
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 1:4735 STATESMEN DR STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-5647
Mailing Address - Country:US
Mailing Address - Phone:317-986-4956
Mailing Address - Fax:317-452-8821
Practice Address - Street 1:4735 STATESMEN DR STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-5647
Practice Address - Country:US
Practice Address - Phone:317-986-4956
Practice Address - Fax:317-452-8821
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008255A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical