Provider Demographics
NPI:1164552154
Name:IACONO RUSSELL, GEORGEANN L (PHD)
Entity Type:Individual
Prefix:
First Name:GEORGEANN
Middle Name:L
Last Name:IACONO RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 DE FOREST LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-5905
Mailing Address - Country:US
Mailing Address - Phone:630-837-8028
Mailing Address - Fax:708-763-2120
Practice Address - Street 1:7411 WEST LAKE STREET
Practice Address - Street 2:BUILDING A, SUITE L120
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1876
Practice Address - Country:US
Practice Address - Phone:708-488-1919
Practice Address - Fax:708-763-2120
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004593103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21623162OtherBCBS GROUP NUMBER
IL207822Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER