Provider Demographics
NPI:1235276072
Name:RUSSELL, LITA WILSON (PHD)
Entity Type:Individual
Prefix:
First Name:LITA
Middle Name:WILSON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 PROVIDENCE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-6219
Mailing Address - Country:US
Mailing Address - Phone:919-601-7985
Mailing Address - Fax:888-208-9941
Practice Address - Street 1:141 PROVIDENCE RD
Practice Address - Street 2:STE 100
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-6219
Practice Address - Country:US
Practice Address - Phone:919-601-7985
Practice Address - Fax:888-208-9941
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2532103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0441WOtherBCBS