Provider Demographics
NPI:1396724225
Name:RUSS-LONG, NATASHA SCARLETT (MSW LCSW)
Entity type:Individual
Prefix:MS
First Name:NATASHA
Middle Name:SCARLETT
Last Name:RUSS-LONG
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1657
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-1657
Mailing Address - Country:US
Mailing Address - Phone:910-879-0218
Mailing Address - Fax:910-879-1018
Practice Address - Street 1:105 W BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9311
Practice Address - Country:US
Practice Address - Phone:910-879-0218
Practice Address - Fax:910-879-1018
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0037521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002569Medicaid
NC133YFOtherBCBS