Healthcare Provider Details

I. General information

NPI: 1750134169
Provider Name (Legal Business Name): BRITTANY ELISE RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MADISON ST
OAK PARK IL
60302-4278
US

IV. Provider business mailing address

413 N PRINCETON AVE
VILLA PARK IL
60181-1923
US

V. Phone/Fax

Practice location:
  • Phone: 708-859-8004
  • Fax:
Mailing address:
  • Phone: 630-746-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180015934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: