Provider Demographics
NPI:1447521505
Name:RUSSELL, JULIE ANN (LICSW)
Entity type:Individual
Prefix:MS
First Name:JULIE
Middle Name:ANN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 7TH ST # 78MDG
Mailing Address - Street 2:
Mailing Address - City:ROBINS AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31098-2227
Mailing Address - Country:US
Mailing Address - Phone:478-327-8487
Mailing Address - Fax:
Practice Address - Street 1:655 SOUTH 7TH STREET BLDG 700/700-A
Practice Address - Street 2:78 MDG/SG3
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098
Practice Address - Country:US
Practice Address - Phone:478-365-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-21
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA83161041C0700X, 1041C0700X
MD120221041C0700X, 1041C0700X
DC500776921041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003457Medicaid