| Doctor Name: | GEORGEANN L IACONO RUSSELL |
| NPI Number: | 1164552154 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PH.D |
| License Number: | 071-004593 |
| Business Practice Address: | 7411 West Lake Street Building A, Suite L120 River Forest, IL - 603051876 |
| Business Phone Number: | 7084881919 |
| Business Fax Number: | 7087632120 |
| Mailing Address: | 1825 De Forest Ln, HANOVER PARK |
| State: | IL |
| Postal Code: | 601335905 |
| Phone Number: | 6308378028 |
| Fax Number: | 7087632120 |
| NPI Enumeration Date: | 03/07/2007 |
| NPI Last Update Date: | 03/11/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | 071-004593 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |