Provider Demographics
NPI:1720231905
Name:RUSSELL, DALTON LEE
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:LEE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1309 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6232
Practice Address - Country:US
Practice Address - Phone:704-933-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor