Provider Demographics
NPI:1346557543
Name:GWILLIAM, RUSSELL JEREMY (MA, LMHC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JEREMY
Last Name:GWILLIAM
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PINEVIEW TRL
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2120
Mailing Address - Country:US
Mailing Address - Phone:508-864-0839
Mailing Address - Fax:
Practice Address - Street 1:44 FRONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1733
Practice Address - Country:US
Practice Address - Phone:508-753-0321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1745251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health