Provider Demographics
NPI:1720719594
Name:TRUSSELL, VICTOR (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:TRUSSELL
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 S DIVINITY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-4301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:524 W BROAD ST
Practice Address - Street 2:
Practice Address - City:QUAKERTOWN
Practice Address - State:PA
Practice Address - Zip Code:18951-1216
Practice Address - Country:US
Practice Address - Phone:215-527-8012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW024314104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker