Healthcare Provider Details

I. General information

NPI: 1699009498
Provider Name (Legal Business Name): JAMES G RUSSELL LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2009
Last Update Date: 09/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 ROBINSON ST
DANVILLE IL
61832-8515
US

IV. Provider business mailing address

102 ROBINSON ST
DANVILLE IL
61832-8515
US

V. Phone/Fax

Practice location:
  • Phone: 217-443-1772
  • Fax: 217-443-1701
Mailing address:
  • Phone: 217-443-1772
  • Fax: 217-443-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.004885
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: