Basic Information
| Provider Information | |||||||||
| NPI: | 1043415276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | CLAUDETTE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSSELL-BARNES | ||||||||
| OtherFirstName: | MONIQUE | ||||||||
| OtherMiddleName: | CLAUDETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 340 TREELINE PARK APT 722 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782091840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9179713321 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4203 WOODCOCK DR STE 216 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782281312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105649116 | ||||||||
| FaxNumber: | 2105649087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 052482 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 61636 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.