Provider Demographics
NPI:1720748601
Name:RUSSELL, NAOMI
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 MARION HWY
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-9313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1117 MARION HWY
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241-9313
Practice Address - Country:US
Practice Address - Phone:318-503-8681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18888104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker