MEDICARE: CYNTHIA MARIE RUSSELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149.013675	IL

General Provider Information

NPI Number	:	1053489450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CYNTHIA MARIE RUSSELL LCSW

Provider Business Mailing Address
First Line	:	271 ELMWOOD LN UNIT A2
Second Line	:
City	:	SCHAUMBURG
State	:	IL
Zip	:	60193-2032
Country	:	US
Telephone Number	:	773-629-3082
Fax Number	:

Provider Business Practice Location Address
First Line	:	460 BRIARGATE DR
Second Line	:	SUITE 700
City	:	SOUTH ELGIN
State	:	IL
Zip	:	60177-2227
Country	:	US
Telephone Number	:	847-488-1999
Fax Number	:	847-488-9797

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	12/20/2019

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