Provider Demographics
NPI:1093716672
Name:GAMBLE, ELIZABETH ANN (PSYD)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:ANN
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 BREEZEWOOD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5281
Mailing Address - Country:US
Mailing Address - Phone:910-677-0000
Mailing Address - Fax:910-677-0099
Practice Address - Street 1:2931 BREEZEWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5281
Practice Address - Country:US
Practice Address - Phone:910-677-0000
Practice Address - Fax:910-677-0099
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1853103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000651Medicaid
NC2821711AMedicaid
NC6000651Medicaid