Provider Demographics
NPI:1891509246
Name:RUSSELL, ALEXIS (LGSW)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 WASHINGTON ST E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25311-2505
Mailing Address - Country:US
Mailing Address - Phone:681-205-8480
Mailing Address - Fax:
Practice Address - Street 1:1511 WASHINGTON ST E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25311-2505
Practice Address - Country:US
Practice Address - Phone:681-205-8480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP00946549171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator