Provider Demographics
NPI:1063567139
Name:RUSSELL, MERCY BURTON (LCSW)
Entity type:Individual
Prefix:
First Name:MERCY
Middle Name:BURTON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:MERCY
Other - Middle Name:RUSSELL
Other - Last Name:HYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:835 SPRUCE ST STE C&D
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3455
Mailing Address - Country:US
Mailing Address - Phone:505-747-7400
Mailing Address - Fax:505-443-8310
Practice Address - Street 1:835 SPRUCE ST STE C&D
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3455
Practice Address - Country:US
Practice Address - Phone:505-747-7400
Practice Address - Fax:505-443-8310
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT89-00002121041C0700X
AZ195501041C0700X
NMSWB-2025-00221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT821-8223OtherVERMONT BCBS PIN
VT89-0000212OtherVERMONT LCSW