Provider Demographics
NPI:1902129059
Name:BREEDEN-SMITH, ANGELINA
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:
Last Name:BREEDEN-SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 KIRK FARM LN
Mailing Address - Street 2:202
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4048
Mailing Address - Country:US
Mailing Address - Phone:704-900-6886
Mailing Address - Fax:
Practice Address - Street 1:1503 KIRK FARM LN
Practice Address - Street 2:202
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-4048
Practice Address - Country:US
Practice Address - Phone:704-900-6886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)