Provider Demographics
NPI:1427280072
Name:RUSSELL, AMANDA LYNN (LCSW-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 OCEAN GTWY
Mailing Address - Street 2:# 4
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-7217
Mailing Address - Country:US
Mailing Address - Phone:410-334-6961
Mailing Address - Fax:
Practice Address - Street 1:29520 CANVASBACK DR
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7124
Practice Address - Country:US
Practice Address - Phone:410-822-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD161811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD522156095OtherAETNA
MD522156095OtherUNITEDE HEALTH CARE
MDR968OtherCAREFIRST BCBS - FEDERAL
MD522156095OtherMHNET
MD522156095OtherTRICARE
MD522156095OtherUNITED BEHAVIORAL HEALTH
MD522156095OtherVALUE OPTIONS
MD499188OtherVO-MHA
MD346646OtherMHN
MDLM49EAOtherCAREFIRST BCBS
MD522156095OtherAMERICAN PSYCH SYSTEM HEALTHCARE
MD609550002Medicaid
MD609550002Medicaid