Provider Demographics
NPI:1528781093
Name:RUSSELL, STACEY (LMSW)
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 DANLOU DR
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-6406
Mailing Address - Country:US
Mailing Address - Phone:410-500-0422
Mailing Address - Fax:
Practice Address - Street 1:4302 DANLOU DR
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-6406
Practice Address - Country:US
Practice Address - Phone:410-500-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24387104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker