Provider Demographics
NPI:1053731760
Name:RUSSELL LEANDER, LCPC
Entity type:Organization
Organization Name:RUSSELL LEANDER, LCPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEANDER
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-807-7734
Mailing Address - Street 1:5115 N RAVENSWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2712
Mailing Address - Country:US
Mailing Address - Phone:773-807-7734
Mailing Address - Fax:
Practice Address - Street 1:1631 W CARMEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2701
Practice Address - Country:US
Practice Address - Phone:773-807-7734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-006834305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization