Provider Demographics
NPI:1053036541
Name:RUSSELL, EMILY (LMSW)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4904 BRIARWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-1304
Mailing Address - Country:US
Mailing Address - Phone:315-378-9428
Mailing Address - Fax:
Practice Address - Street 1:650 MADISON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2338
Practice Address - Country:US
Practice Address - Phone:315-426-7737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101817104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker