Provider Demographics
NPI:1770342420
Name:RUSSELL, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 JAYLEE DR UNIT 1
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5273
Mailing Address - Country:US
Mailing Address - Phone:208-419-9383
Mailing Address - Fax:
Practice Address - Street 1:1200 JAYLEE DR UNIT 1
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5273
Practice Address - Country:US
Practice Address - Phone:208-419-9383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No251S00000XAgenciesCommunity/Behavioral Health