Provider Demographics
NPI:1588765614
Name:RUSSELL, LARRY WAYNE (LSW MA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LSW MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:RICHWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26261-1307
Mailing Address - Country:US
Mailing Address - Phone:304-847-5425
Mailing Address - Fax:304-847-5422
Practice Address - Street 1:70 PARCOAL RD
Practice Address - Street 2:
Practice Address - City:WEBSTER SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:26288-9767
Practice Address - Country:US
Practice Address - Phone:304-847-5425
Practice Address - Fax:304-847-5422
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00940954104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000479Medicaid