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NPI Code Detail

MEDICARE: MRS. AMANDA RUSSELL CSW

MEDICARE: MRS. AMANDA RUSSELL CSW
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
1101YM0800XMental Health Counselor5922570-3502UT
21041C0700XClinical Social Worker5922570-3501UT

Other Identifiers

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

General Provider Information

NPI Number : 1699730952
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. AMANDA RUSSELL CSW
Provider Business Mailing Address
First Line : 2828 S 1000 E
Second Line :
City : SLC
State : UT
Zip : 84106-2278
Country : US
Telephone Number : 801-972-2711
Fax Number : 801-972-2709
Provider Business Practice Location Address
First Line : 1578 W 1700 S
Second Line : #200
City : SLC
State : UT
Zip : 84104-3470
Country : US
Telephone Number : 801-972-2711
Fax Number : 801-972-2709
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/19/2006
Last Update Date : 02/25/2022

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Directions to “ MRS. AMANDA RUSSELL CSW” Practice Location

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