Provider Demographics
NPI:1548517642
Name:RUSSELL, AMANDA LEE (BCBA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CANTERBURY ST
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-3529
Mailing Address - Country:US
Mailing Address - Phone:413-464-1925
Mailing Address - Fax:
Practice Address - Street 1:6 SOUTHSIDE RD
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1409
Practice Address - Country:US
Practice Address - Phone:413-464-1925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst