Provider Demographics
NPI:1972224285
Name:RUSSELL - WILLIAMS, MARLANE (MA, NCC, RIC)
Entity type:Individual
Prefix:
First Name:MARLANE
Middle Name:
Last Name:RUSSELL - WILLIAMS
Suffix:
Gender:F
Credentials:MA, NCC, RIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12309 WOODLAWN CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1920
Mailing Address - Country:US
Mailing Address - Phone:703-625-4792
Mailing Address - Fax:
Practice Address - Street 1:12309 WOODLAWN CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-1920
Practice Address - Country:US
Practice Address - Phone:703-625-4792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1603620Medicaid