1255321592 NPI number — MRS. DORIS ANN MOORE-RUSSELL LCSW

Table of content: MRS. DORIS ANN MOORE-RUSSELL LCSW (NPI 1255321592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255321592 NPI number — MRS. DORIS ANN MOORE-RUSSELL LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE-RUSSELL
Provider First Name:
DORIS
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255321592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6208 KING HIRAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOPE MILLS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28348-9767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-429-0543
Provider Business Mailing Address Fax Number:
910-429-0543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 LAMON ST
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28301-4957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-429-2222
Provider Business Practice Location Address Fax Number:
910-429-2222
Provider Enumeration Date:
10/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  C004369 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 365036 . This is a "MANAGED HEALTH NETWORK" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6002914 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 136AJ . This is a "BC/BS OF NORTH CAROLINA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 522556 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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