Provider Demographics
NPI:1285905968
Name:BUSTLE, VIRGINIA DERBY (LCSW)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:DERBY
Last Name:BUSTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 HUNTLEIGH DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-3312
Mailing Address - Country:US
Mailing Address - Phone:919-771-7833
Mailing Address - Fax:
Practice Address - Street 1:809 SPRING FOREST RD STE 1000
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-9147
Practice Address - Country:US
Practice Address - Phone:919-771-7833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0021971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical