Healthcare Provider Details

I. General information

NPI: 1366543167
Provider Name (Legal Business Name): KEVIN JOHN RUSSELL LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 BULL VALLEY RD STE 106
MCHENRY IL
60050-2209
US

IV. Provider business mailing address

5435 BULL VALLEY RD STE 106
MCHENRY IL
60050-2209
US

V. Phone/Fax

Practice location:
  • Phone: 815-382-8378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180002771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: