Provider Demographics
NPI:1164563417
Name:RUSSELL, VICTOR JONES (LCAS, CSAC)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:JONES
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:LCAS, CSAC
Other - Prefix:MRS
Other - First Name:SHARITA
Other - Middle Name:
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:230 SPRING DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-9161
Mailing Address - Country:US
Mailing Address - Phone:910-285-5527
Mailing Address - Fax:910-285-5526
Practice Address - Street 1:116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2902
Practice Address - Country:US
Practice Address - Phone:910-285-5527
Practice Address - Fax:910-285-5526
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0558101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)