Provider Demographics
NPI:1700137122
Name:RUSSELL, TERESA PAYTON
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:PAYTON
Last Name:RUSSELL
Suffix:
Gender:F
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:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:1000 N 1ST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-2833
Practice Address - Country:US
Practice Address - Phone:704-983-2117
Practice Address - Fax:704-983-2636
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor