Healthcare Provider Details

I. General information

NPI: 1689845620
Provider Name (Legal Business Name): ANN CAROL RUSSELL LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

IV. Provider business mailing address

2905 NORTH MAIN STREET
DECATUR IL
62526
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-1558
  • Fax: 217-366-0160
Mailing address:
  • Phone: 217-877-9117
  • Fax: 217-877-3077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: