Provider Demographics
NPI:1023136207
Name:RUSSELL, ELIZABETH MARIE (PT,CLT-LANA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PT,CLT-LANA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1101 CIRCLE AVE
Mailing Address - Street 2:1101 CIRCLE AVENUE
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2326
Mailing Address - Country:US
Mailing Address - Phone:708-488-0520
Mailing Address - Fax:
Practice Address - Street 1:143 BERNICE DR
Practice Address - Street 2:143 BERNICE DRIVE
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-3366
Practice Address - Country:US
Practice Address - Phone:630-350-2736
Practice Address - Fax:630-350-2842
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist