Provider Demographics
NPI:1881000826
Name:MCCORMACK, RUSSELL SCOTT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:SCOTT
Last Name:MCCORMACK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 TEE GIRL CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-4380
Mailing Address - Country:US
Mailing Address - Phone:630-904-1014
Mailing Address - Fax:
Practice Address - Street 1:24020 W RIVERWALK CT
Practice Address - Street 2:#100
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-7103
Practice Address - Country:US
Practice Address - Phone:815-577-8970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.005439103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical