Healthcare Provider Details

I. General information

NPI: 1275916223
Provider Name (Legal Business Name): AMY BONIFAY RUSSELL PSY. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2469 E FORT UNION BLVD STE 206
SALT LAKE CITY UT
84121-3417
US

IV. Provider business mailing address

2469 EAST FORT UNION BLVD #206
SLC UT
84121
US

V. Phone/Fax

Practice location:
  • Phone: 801-300-6223
  • Fax:
Mailing address:
  • Phone: 801-300-6223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4802206-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: