Provider Demographics
NPI:1497925093
Name:FLECK, J ROLAND (EDD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:ROLAND
Last Name:FLECK
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 MANCHESTER AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-4940
Mailing Address - Country:US
Mailing Address - Phone:760-942-1210
Mailing Address - Fax:760-942-3965
Practice Address - Street 1:4405 MANCHESTER AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-4940
Practice Address - Country:US
Practice Address - Phone:760-942-1210
Practice Address - Fax:760-942-3965
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 5502103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP 5502Medicare PIN