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General NPI Number Information
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NPI Number | 1831282441
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Entity Type | Individual
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Provider Name | MICHAEL GUY RUSSELL LCSW
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Gender | Male
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 06/15/2023
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Provider Practice Location Address
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Address Line | 8 WEST MONROE #907
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City | CHICAGO
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State | IL
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Zip | 60603
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Country | US
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Telephone | 312-345-9042
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Fax |
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Provider Business Mailing Address
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Address Line | 5941 W CORCORAN PL APT 1W
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City | CHICAGO
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State | IL
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Zip | 60644-1868
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Country | US
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Telephone | 312-933-0509
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149007782
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License Number State | IL
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