Basic Information
| Provider Information | |||||||||
| NPI: | 1407005937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MSW, LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128866800 | ||||||||
| FaxNumber: | 8128866809 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PETERSBURG | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475671245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123548785 | ||||||||
| FaxNumber: | 8123548786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 03/03/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 33005551A | IN | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.