Individual
KILEY RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
5100 S DORCHESTER AVE, CHICAGO, IL 60615-4118
(773) 966-5039
Mailing address
5100 S DORCHESTER AVE, CHICAGO, IL 60615-4118
(773) 966-5039
Taxonomy
Speciality
Code
Description
License number
State
222Q00000X
Developmental Therapist
Primary
—
—
Other
Enumeration date
11/13/2023
Last updated
11/13/2023
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