Provider Demographics
NPI:1588055313
Name:MARTIN, RUSSELL ANTHONY (LMSW)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ANTHONY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:242 BRADHURST AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-1421
Mailing Address - Country:US
Mailing Address - Phone:646-251-7869
Mailing Address - Fax:
Practice Address - Street 1:242 BRADHURST AVE APT 22
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-1421
Practice Address - Country:US
Practice Address - Phone:646-251-7869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091178-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical