Provider Demographics
NPI:1912983685
Name:RUSSELL, BETTY WRIGHT (LCSW, LMFT, PHD)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:WRIGHT
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LCSW, LMFT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 WILLIAMSON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5964
Mailing Address - Country:US
Mailing Address - Phone:704-664-7148
Mailing Address - Fax:704-664-3086
Practice Address - Street 1:363 WILLIAMSON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5964
Practice Address - Country:US
Practice Address - Phone:704-664-7148
Practice Address - Fax:704-664-3086
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0009141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC74043OtherBLUECROSS BLUESHIELD OF N
NC2862897AMedicare ID - Type Unspecified