Provider Demographics
NPI:1740839539
Name:RUSSELL, CHRISTINE BLAIR (LCSW)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:BLAIR
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:BLAIR
Other - Last Name:DOOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:804 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1753
Mailing Address - Country:US
Mailing Address - Phone:682-560-5652
Mailing Address - Fax:
Practice Address - Street 1:321 HAMILTON ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2148
Practice Address - Country:US
Practice Address - Phone:630-686-2282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0214311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical