Individual
GEORGEANN L IACONO RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PH.D
Contact information
Practice address
7411 WEST LAKE STREET, BUILDING A, SUITE L120, RIVER FOREST, IL 60305-1876
(708) 488-1919
(708) 763-2120
Mailing address
1825 DE FOREST LN, HANOVER PARK, IL 60133-5905
(630) 837-8028
(708) 763-2120
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
071-004593
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
21623162
BCBS GROUP NUMBER
IL
Enumeration date
03/07/2007
Last updated
03/11/2011
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