MEDICARE: DR. AMY BONIFAY RUSSELL PSY. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	4802206-2501	UT

General Provider Information

NPI Number	:	1275916223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY BONIFAY RUSSELL PSY. D.

Provider Business Mailing Address
First Line	:	2469 EAST FORT UNION BLVD #206
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84121
Country	:	US
Telephone Number	:	801-300-6223
Fax Number	:

Provider Business Practice Location Address
First Line	:	2469 E FORT UNION BLVD STE 206
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3417
Country	:	US
Telephone Number	:	801-300-6223
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2015
Last Update Date	:	07/08/2015

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