Provider Demographics
NPI:1952016545
Name:RUSSELL, AMANDA (LLMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60005 CAMPGROUND RD STE 400
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48094-3446
Mailing Address - Country:US
Mailing Address - Phone:586-232-5089
Mailing Address - Fax:
Practice Address - Street 1:60005 CAMPGROUND RD STE 400
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48094-3446
Practice Address - Country:US
Practice Address - Phone:586-232-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511100371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical