Provider Demographics
NPI:1598514556
Name:RUSSELL, MALERIE LYNN (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:MALERIE
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W RAILROAD ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-1513
Mailing Address - Country:US
Mailing Address - Phone:989-640-5467
Mailing Address - Fax:
Practice Address - Street 1:201 W RAILROAD ST STE A
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1513
Practice Address - Country:US
Practice Address - Phone:989-640-5467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851107813104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker