Healthcare Provider Details

I. General information

NPI: 1164552154
Provider Name (Legal Business Name): GEORGEANN L IACONO RUSSELL PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 03/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7411 WEST LAKE STREET BUILDING A, SUITE L120
RIVER FOREST IL
60305-1876
US

IV. Provider business mailing address

1825 DE FOREST LN
HANOVER PARK IL
60133-5905
US

V. Phone/Fax

Practice location:
  • Phone: 708-488-1919
  • Fax: 708-763-2120
Mailing address:
  • Phone: 630-837-8028
  • Fax: 708-763-2120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-004593
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: