Healthcare Provider Details

I. General information

NPI: 1396724225
Provider Name (Legal Business Name): NATASHA SCARLETT RUSS-LONG MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W BROAD ST
ELIZABETHTOWN NC
28337-9311
US

IV. Provider business mailing address

PO BOX 1657
ELIZABETHTOWN NC
28337-1657
US

V. Phone/Fax

Practice location:
  • Phone: 910-879-0218
  • Fax: 910-879-1018
Mailing address:
  • Phone: 910-879-0218
  • Fax: 910-879-1018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC003752
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: