MEDICARE: KELLY RUSSELL

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	103K00000X	Behavior Analyst	152.001292	IL

General Provider Information

NPI Number	:	1184586786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY RUSSELL

Provider Business Mailing Address
First Line	:	8397 W 131ST ST
Second Line	:
City	:	PALOS PARK
State	:	IL
Zip	:	60464-2190
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1813 N MILL ST STE A
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60563-4872
Country	:	US
Telephone Number	:	331-303-8600
Fax Number	:

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

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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Directions to “ KELLY RUSSELL ” Practice Location

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