Provider Demographics
NPI:1801021829
Name:RUSSELL, AMANDA JEAN (MA CF/SLP)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JEAN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MA CF/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 ALEXANDRIA PIKE STE 108
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-3500
Mailing Address - Country:US
Mailing Address - Phone:859-572-0430
Mailing Address - Fax:859-572-0163
Practice Address - Street 1:4150 ALEXANDRIA PIKE STE 108
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076-3500
Practice Address - Country:US
Practice Address - Phone:859-572-0430
Practice Address - Fax:859-572-0163
Is Sole Proprietor?:No
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY08071235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist