Provider Demographics
NPI:1326397670
Name:RUSSELL, AMANDA HARTZ (AUD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:HARTZ
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 HENRY TECKLENBURG DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-7801
Mailing Address - Country:US
Mailing Address - Phone:843-766-7103
Mailing Address - Fax:843-377-4629
Practice Address - Street 1:2295 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7801
Practice Address - Country:US
Practice Address - Phone:843-766-7103
Practice Address - Fax:843-377-4629
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA#358231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4142OtherSTATE LICENSE