Individual
MRS. AMANDA RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CSW
Contact information
Practice address
1578 W 1700 S, #200, SLC, UT 84104-3470
(801) 972-2711
(801) 972-2709
Mailing address
2828 S 1000 E, SLC, UT 84106-2278
(801) 972-2711
(801) 972-2709
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
5922570-3502
UT
1041C0700X
Clinical Social Worker
Primary
5922570-3501
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
788007788049
—
UT
Enumeration date
04/19/2006
Last updated
02/25/2022
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