Basic Information
| Provider Information | |||||||||
| NPI: | 1689862294 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARSK | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LESLIE | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCSWA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6121 GRAY GATE LN APT C | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282104034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045766367 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1190 W ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281102818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042966200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P010783 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.