Provider Demographics
NPI:1104711357
Name:RUSS, TABITHA LYNN (MSW, LCSWA)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYNN
Last Name:RUSS
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 S MCPHERSON CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5184
Mailing Address - Country:US
Mailing Address - Phone:910-849-3399
Mailing Address - Fax:910-900-0913
Practice Address - Street 1:951 S MCPHERSON CHURCH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5184
Practice Address - Country:US
Practice Address - Phone:910-849-3399
Practice Address - Fax:910-900-0913
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0218831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical