Provider Demographics
NPI:1093529059
Name:RUSSELL, DARLEEN
Entity type:Individual
Prefix:
First Name:DARLEEN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20053
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-0353
Mailing Address - Country:US
Mailing Address - Phone:267-992-1081
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 20053
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-0353
Practice Address - Country:US
Practice Address - Phone:267-992-1081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-01
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAPC000802101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty