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General NPI Number Information
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NPI Number | 1730699182
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Entity Type | Individual
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Provider Name | ANDREA RUSSELL LCPC
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Gender | Female
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Dates
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Enumeration Date | 10/11/2017
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Last Update Date | 10/11/2017
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Provider Practice Location Address
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Address Line | 20280 GOVERNORS HWY STE 207
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1028
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Country | US
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Telephone | 708-794-6461
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Fax |
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Provider Business Mailing Address
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Address Line | 825 E 41ST ST APT 1B
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City | CHICAGO
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State | IL
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Zip | 60653-2481
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180010847
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License Number State | IL
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