MEDICARE: ANDREA SYNNESTVEDT RUSSELL LMSW

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	104100000X	Social Worker	6801085121	MI

General Provider Information

NPI Number	:	1992803795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA SYNNESTVEDT RUSSELL LMSW

Provider Business Mailing Address
First Line	:	800 COTTAGEVIEW DR STE 1076
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2614
Country	:	US
Telephone Number	:	231-218-6664
Fax Number	:

Provider Business Practice Location Address
First Line	:	4230 COPPER RIDGE DR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7256
Country	:	US
Telephone Number	:	231-935-6380
Fax Number	:	231-935-6920

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	01/17/2024

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