Provider Demographics
NPI:1184959223
Name:RUSSELL, AMBER (LCSW)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 OLD OCEAN HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-2632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85 OLD OCEAN HOUSE RD
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-2632
Practice Address - Country:US
Practice Address - Phone:207-482-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-07
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC118351041C0700X
MELC130101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical