Healthcare Provider Details

I. General information

NPI: 1629941281
Provider Name (Legal Business Name): MARY ADAIR MELTON RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 32ND ST SW
HICKORY NC
28602-4633
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 828-324-8884
  • Fax: 828-345-6226
Mailing address:
  • Phone: 704-874-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP019779
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: