Provider Demographics
NPI:1558148171
Name:RUSSO, HANNAH
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3054 N AVERS AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-8972
Mailing Address - Country:US
Mailing Address - Phone:847-917-5835
Mailing Address - Fax:
Practice Address - Street 1:3054 N AVERS AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-8972
Practice Address - Country:US
Practice Address - Phone:847-917-5835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2492455103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty