Provider Demographics
NPI:1013039502
Name:RUSSELL, GAY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GAY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GAY
Other - Middle Name:
Other - Last Name:MCCALLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:904 S ROSELLE ROAD UNIT 364
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193
Mailing Address - Country:US
Mailing Address - Phone:847-340-9297
Mailing Address - Fax:847-985-1465
Practice Address - Street 1:148 S BLOOMINGDALE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108
Practice Address - Country:US
Practice Address - Phone:630-894-4451
Practice Address - Fax:630-894-2876
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490112091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02221520OtherBCBS