Provider Demographics
NPI:1699730952
Name:RUSSELL, AMANDA (CSW)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 S 1000 E
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2278
Mailing Address - Country:US
Mailing Address - Phone:801-972-2711
Mailing Address - Fax:801-972-2709
Practice Address - Street 1:1578 W 1700 S
Practice Address - Street 2:#200
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84104-3470
Practice Address - Country:US
Practice Address - Phone:801-972-2711
Practice Address - Fax:801-972-2709
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5922570-3502101YM0800X
UT5922570-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788049Medicaid