Provider Demographics
NPI:1891248100
Name:BERNAL, ANGELIQUE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:BERNAL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 WILLOW BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7039
Mailing Address - Country:US
Mailing Address - Phone:704-577-1951
Mailing Address - Fax:
Practice Address - Street 1:8101 WILLOW BRANCH DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7039
Practice Address - Country:US
Practice Address - Phone:704-577-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1891248100Medicaid