Basic Information
| Provider Information | |||||||||
| NPI: | 1710005376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCARBOROUGH | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | SAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 7 LKS N | ||||||||
| Address2: | PO BOX 9 | ||||||||
| City: | WEST END | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273769756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106739111 | ||||||||
| FaxNumber: | 9106736202 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 OLD LILESVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WADESBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281702820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046946588 | ||||||||
| FaxNumber: | 7046946706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.