Provider Demographics
NPI:1730699182
Name:RUSSELL, ANDREA (LCPC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E 41ST ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-2481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20280 GOVERNORS HWY STE 207
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1028
Practice Address - Country:US
Practice Address - Phone:708-794-6461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010847101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional