Provider Demographics
NPI:1831783109
Name:ELLEVEN, RUSSELL (DMIN, EDD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:ELLEVEN
Suffix:
Gender:M
Credentials:DMIN, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2743
Mailing Address - Country:US
Mailing Address - Phone:312-330-5353
Mailing Address - Fax:
Practice Address - Street 1:201 S STEWART AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2743
Practice Address - Country:US
Practice Address - Phone:312-330-5353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36465101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty