Provider Demographics
NPI:1952094880
Name:RUSSELL, MICHAEL J II (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:RUSSELL
Suffix:II
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6470 N OLYMPIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1519
Mailing Address - Country:US
Mailing Address - Phone:773-682-9633
Mailing Address - Fax:
Practice Address - Street 1:250 S NW HIGHWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:888-428-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-26
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178019110101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional