Provider Demographics
NPI:1699009498
Name:RUSSELL, JAMES G (LCPC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-8515
Mailing Address - Country:US
Mailing Address - Phone:217-443-1772
Mailing Address - Fax:217-443-1701
Practice Address - Street 1:102 ROBINSON ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-8515
Practice Address - Country:US
Practice Address - Phone:217-443-1772
Practice Address - Fax:217-443-1701
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.004885101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional