Provider Demographics
NPI:1962425975
Name:WEATHERSBY, RUSSELL A (LCSW)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:A
Last Name:WEATHERSBY
Suffix:
Gender:M
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:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:ZEPHYR COVE
Mailing Address - State:NV
Mailing Address - Zip Code:89448-0574
Mailing Address - Country:US
Mailing Address - Phone:828-713-5496
Mailing Address - Fax:
Practice Address - Street 1:154 MEDICAL PARK LOOP
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-5222
Practice Address - Country:US
Practice Address - Phone:828-631-3973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL48651041C0700X
NV5103-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003455Medicaid
NC135RNOtherBCBS NC
NC6003455Medicaid