MEDICARE: MISS ELIZABETH ANN GAMBLE PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	1853	NC
2	103G00000X	Clinical Neuropsychologist	1853	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093716672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ELIZABETH ANN GAMBLE PSY.D.

Provider Business Mailing Address
First Line	:	2931 BREEZEWOOD AVE STE 100
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5281
Country	:	US
Telephone Number	:	910-677-0000
Fax Number	:	910-677-0099

Provider Business Practice Location Address
First Line	:	2931 BREEZEWOOD AVE STE 100
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5281
Country	:	US
Telephone Number	:	910-677-0000
Fax Number	:	910-677-0099

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	01/07/2021

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