Provider Demographics
NPI:1255321592
Name:MOORE-RUSSELL, DORIS ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DORIS
Middle Name:ANN
Last Name:MOORE-RUSSELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6208 KING HIRAM RD
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-9767
Mailing Address - Country:US
Mailing Address - Phone:910-429-0543
Mailing Address - Fax:910-429-0543
Practice Address - Street 1:111 LAMON ST
Practice Address - Street 2:SUITE 212
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4957
Practice Address - Country:US
Practice Address - Phone:910-429-2222
Practice Address - Fax:910-429-2222
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0043691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC365036OtherMANAGED HEALTH NETWORK
NC6002914Medicaid
NC136AJOtherBC/BS OF NORTH CAROLINA
NC522556OtherVALUE OPTIONS
NC136AJOtherBC/BS OF NORTH CAROLINA