Individual
AMANDA RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
120 E 5TH NORTH ST, SUMMERVILLE, SC 29483-6822
(843) 826-0665
Mailing address
120 E 5TH NORTH ST, SUMMERVILLE, SC 29483-6822
(843) 826-0665
Taxonomy
Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
17-41549
SC
106S00000X
Behavior Technician
BACB380191
SC
Other
Enumeration date
05/22/2018
Last updated
09/27/2021
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