Provider Demographics
NPI:1992803795
Name:RUSSELL, ANDREA SYNNESTVEDT (LMSW)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:SYNNESTVEDT
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 COTTAGEVIEW DR STE 1076
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2614
Mailing Address - Country:US
Mailing Address - Phone:231-218-6664
Mailing Address - Fax:
Practice Address - Street 1:4230 COPPER RIDGE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7256
Practice Address - Country:US
Practice Address - Phone:231-935-6380
Practice Address - Fax:231-935-6920
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801085121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker