MEDICARE: MADELINE MARIE RUSSELL

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	101YM0800X	Mental Health Counselor	A22081	NC

General Provider Information

NPI Number	:	1891659413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELINE MARIE RUSSELL

Provider Business Mailing Address
First Line	:	1314 GOODVIEW AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-4823
Country	:	US
Telephone Number	:	910-228-8790
Fax Number	:

Provider Business Practice Location Address
First Line	:	1804 MARTIN LUTHER KING PKWY
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27707-3587
Country	:	US
Telephone Number	:	919-246-5664
Fax Number	:

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

Provider Enumeration Date	:	12/10/2025
Last Update Date	:	12/10/2025

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