Provider Demographics
NPI:1710290671
Name:RUSSELL, LISA R
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:R
Last Name:RUSSELL
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 1:3999 WHISPERING TRAILS CT
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60192-1547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3999 WHISPERING TRAILS CT
Practice Address - Street 2:
Practice Address - City:HOFFMAN ESTATES
Practice Address - State:IL
Practice Address - Zip Code:60192-1547
Practice Address - Country:US
Practice Address - Phone:847-874-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.005792225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics