Provider Demographics
NPI:1750786232
Name:RUSSELL, AMELIA
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W THOUSAND OAKS BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4402
Mailing Address - Country:US
Mailing Address - Phone:805-777-3595
Mailing Address - Fax:805-777-3521
Practice Address - Street 1:125 W THOUSAND OAKS BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4402
Practice Address - Country:US
Practice Address - Phone:805-777-3595
Practice Address - Fax:805-777-3521
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health