Provider Demographics
NPI:1922490986
Name:RUSS, AMY (MS)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RUSS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:896 BEAVERBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-1603
Mailing Address - Country:US
Mailing Address - Phone:512-771-0356
Mailing Address - Fax:
Practice Address - Street 1:896 BEAVERBROOK DR NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-1603
Practice Address - Country:US
Practice Address - Phone:512-771-0356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-28
Last Update Date:2015-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health