Healthcare Provider Details

I. General information

NPI: 1427142538
Provider Name (Legal Business Name): ANDREA CODY RUSSELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 SW BEVELAND RD
TIGARD OR
97223-8610
US

IV. Provider business mailing address

16210 PARKER RD
LAKE OSWEGO OR
97035-4038
US

V. Phone/Fax

Practice location:
  • Phone: 503-624-2600
  • Fax:
Mailing address:
  • Phone: 503-675-2981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL1143
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier164936
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: