Provider Demographics
NPI:1831282441
Name:RUSSELL, MICHAEL GUY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GUY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5941 W CORCORAN PL APT 1W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60644-1868
Mailing Address - Country:US
Mailing Address - Phone:312-933-0509
Mailing Address - Fax:
Practice Address - Street 1:8 WEST MONROE
Practice Address - Street 2:#907
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603
Practice Address - Country:US
Practice Address - Phone:312-345-9042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490077821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201693Medicare ID - Type Unspecified