Provider Demographics
NPI:1265976401
Name:SPECK, ANGELA JEAN (MED, EDS)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:JEAN
Last Name:SPECK
Suffix:
Gender:F
Credentials:MED, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LITTLE RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9108
Mailing Address - Country:US
Mailing Address - Phone:252-362-1726
Mailing Address - Fax:
Practice Address - Street 1:1129 HORSESHOE RD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-8507
Practice Address - Country:US
Practice Address - Phone:252-335-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5138103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist