Basic Information
| Provider Information | |||||||||
| NPI: | 1992022669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 N SPRUCE ST | ||||||||
| Address2: | VA MENTAL HEALTH | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809051436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193275660 | ||||||||
| FaxNumber: | 7196338741 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 N SPRUCE ST | ||||||||
| Address2: | VA MENTAL HEALTH | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809051436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193275660 | ||||||||
| FaxNumber: | 7196338741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 107906 | MA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.