Provider Demographics
NPI:1750091823
Name:RUSSELL-PEABODY, LAURIE RAE (LCSWA, MSW, BSW)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:RAE
Last Name:RUSSELL-PEABODY
Suffix:
Gender:F
Credentials:LCSWA, MSW, BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 DEBUT AVE
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-7563
Mailing Address - Country:US
Mailing Address - Phone:585-403-9234
Mailing Address - Fax:
Practice Address - Street 1:705 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-7020
Practice Address - Country:US
Practice Address - Phone:910-485-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPQ184051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114167806Medicaid