Provider Demographics
NPI:1285266734
Name:RUSSELL, SEBRINA
Entity type:Individual
Prefix:
First Name:SEBRINA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 PAXTON LN SW APT 105
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3390
Mailing Address - Country:US
Mailing Address - Phone:601-466-7671
Mailing Address - Fax:
Practice Address - Street 1:409 ARROWHEAD BLVD STE C1&C2
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1255
Practice Address - Country:US
Practice Address - Phone:404-391-7675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW007839104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker