MEDICARE: MRS. DORIS ANN MOORE-RUSSELL LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C004369	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	365036	OTHER	NC	MANAGED HEALTH NETWORK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	136AJ	OTHER	NC	BC/BS OF NORTH CAROLINA
4	522556	OTHER	NC	VALUE OPTIONS

General Provider Information

NPI Number	:	1255321592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DORIS ANN MOORE-RUSSELL LCSW

Provider Business Mailing Address
First Line	:	6208 KING HIRAM RD
Second Line	:
City	:	HOPE MILLS
State	:	NC
Zip	:	28348-9767
Country	:	US
Telephone Number	:	910-429-0543
Fax Number	:	910-429-0543

Provider Business Practice Location Address
First Line	:	111 LAMON ST
Second Line	:	SUITE 212
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-4957
Country	:	US
Telephone Number	:	910-429-2222
Fax Number	:	910-429-2222

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	07/08/2007

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