Basic Information
| Provider Information | |||||||||
| NPI: | 1629119557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5139 1 4 WEST ADAMS BLVD. | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900162729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234232996 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4211 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900115622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234325185 | ||||||||
| FaxNumber: | 3234325086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 05/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 28080 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.