Provider Demographics
NPI:1235957044
Name:RUSSELL, THOMAS CHARLES SR (SOCIAL WORK)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:CHARLES
Last Name:RUSSELL
Suffix:SR
Gender:M
Credentials:SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N 1950 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3100
Mailing Address - Country:US
Mailing Address - Phone:435-201-9389
Mailing Address - Fax:
Practice Address - Street 1:449 N SR 118
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2378
Practice Address - Country:US
Practice Address - Phone:435-201-9389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-158431041C0700X
UT12282390-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical