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General NPI Number Information
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NPI Number | 1053731760
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Entity Type | Organization
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Legal Business Name | RUSSELL LEANDER, LCPC
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Dates
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Enumeration Date | 04/21/2014
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Last Update Date | 04/21/2014
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Provider Practice Location Address
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Address Line | 1631 W CARMEN AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2701
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Country | US
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Telephone | 773-807-7734
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Fax |
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Provider Business Mailing Address
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Address Line | 5115 N RAVENSWOOD AVE
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City | CHICAGO
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State | IL
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Zip | 60640-2712
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Country | US
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Telephone | 773-807-7734
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. RUSSELL J LEANDER
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Credential | LCPC
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Telephone | 773-807-7734
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 180-006834
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License Number State | IL
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