Provider Demographics
NPI:1851841969
Name:RUSSELL, AMANDA LOUISE (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LOUISE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 PROMINENCE CT
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-5412
Mailing Address - Country:US
Mailing Address - Phone:208-610-6459
Mailing Address - Fax:208-694-2139
Practice Address - Street 1:1218 N DIVISION AVE STE 217
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5054
Practice Address - Country:US
Practice Address - Phone:208-610-6459
Practice Address - Fax:208-694-2139
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW36080104100000X
IDLCSW-382051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker