MEDICARE: TAYLOR RUSSELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149017706	IL

General Provider Information

NPI Number	:	1659731768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR RUSSELL LCSW

Provider Business Mailing Address
First Line	:	2049 RIDGE AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-2713
Country	:	US
Telephone Number	:	847-733-2276
Fax Number	:

Provider Business Practice Location Address
First Line	:	2049 RIDGE AVE
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60201-2713
Country	:	US
Telephone Number	:	847-733-2276
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2016
Last Update Date	:	03/02/2016

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