Provider Demographics
NPI:1003236902
Name:RUSSELL, AMANDA (MSED, ATC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MSED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:AMESBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01913-2215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:AMESBURY
Practice Address - State:MA
Practice Address - Zip Code:01913-2215
Practice Address - Country:US
Practice Address - Phone:978-388-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer