Provider Demographics
NPI:1982334173
Name:RUSSELL, AMANDA RAE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
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 1:1607 ORIOLE LN
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1110
Mailing Address - Country:US
Mailing Address - Phone:314-496-9344
Mailing Address - Fax:
Practice Address - Street 1:9350 GREEN PARK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7211
Practice Address - Country:US
Practice Address - Phone:413-845-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018032994224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant