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General NPI Number Information
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NPI Number | 1851841969
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Entity Type | Individual
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Provider Name | AMANDA LOUISE RUSSELL LCSW
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Gender | Female
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Dates
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Enumeration Date | 10/12/2016
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Last Update Date | 03/05/2024
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Provider Practice Location Address
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Address Line | 1218 N DIVISION AVE STE 217
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City | SANDPOINT
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State | ID
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Zip | 83864-5054
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Country | US
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Telephone | 208-610-6459
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Fax | 208-694-2139
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Provider Business Mailing Address
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Address Line | 1317 PROMINENCE CT
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City | SANDPOINT
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State | ID
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Zip | 83864-5412
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Country | US
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Telephone | 208-610-6459
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Fax | 208-694-2139
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | LMSW36080
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-38205
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License Number State | ID
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