MEDICARE: ANDREA CODY RUSSELL LCSW

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	1041C0700X	Clinical Social Worker	L1143	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427142538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA CODY RUSSELL LCSW

Provider Business Mailing Address
First Line	:	16210 PARKER RD
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-4038
Country	:	US
Telephone Number	:	503-675-2981
Fax Number	:

Provider Business Practice Location Address
First Line	:	7455 SW BEVELAND RD
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97223-8610
Country	:	US
Telephone Number	:	503-624-2600
Fax Number	:

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	07/09/2007

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