Provider Demographics
NPI:1275916223
Name:RUSSELL, AMY BONIFAY (PSY D)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:BONIFAY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2469 EAST FORT UNION BLVD #206
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84121
Mailing Address - Country:US
Mailing Address - Phone:801-300-6223
Mailing Address - Fax:
Practice Address - Street 1:2469 E FORT UNION BLVD STE 206
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3417
Practice Address - Country:US
Practice Address - Phone:801-300-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4802206-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical