Provider Demographics
NPI:1124306576
Name:RUSSELL, ANDREA (LCSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1436 S SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1107
Mailing Address - Country:US
Mailing Address - Phone:502-636-0771
Mailing Address - Fax:
Practice Address - Street 1:1436 S SHELBY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1195
Practice Address - Country:US
Practice Address - Phone:502-636-0771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171M00000X
KY2552511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator