Provider Demographics
NPI:1588857619
Name:ALBEMARLE PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:ALBEMARLE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:252-338-8821
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27907
Mailing Address - Country:US
Mailing Address - Phone:252-338-8821
Mailing Address - Fax:252-338-6459
Practice Address - Street 1:301 E CHURCH STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-8821
Practice Address - Fax:252-338-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNCHSP0954103T00000X
NCNCHSP0956103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000148Medicaid
NC39847OtherOPTIMA
NC04098OtherBLUE CROSS
NC94483OtherMEDCOST
NC03119OtherBLUE CROSS
NC6000147Medicaid
NC94483OtherMEDCOST
NC249094AMedicare UPIN
NC1404Medicare PIN