Healthcare Provider Details

I. General information

NPI: 1750786232
Provider Name (Legal Business Name): AMELIA RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W THOUSAND OAKS BLVD SUITE 500
THOUSAND OAKS CA
91360-4402
US

IV. Provider business mailing address

125 W THOUSAND OAKS BLVD SUITE 500
THOUSAND OAKS CA
91360-4402
US

V. Phone/Fax

Practice location:
  • Phone: 805-777-3595
  • Fax: 805-777-3521
Mailing address:
  • Phone: 805-777-3595
  • Fax: 805-777-3521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: