Provider Demographics
NPI:1174681209
Name:DEVEREUX, NANCY M (PHD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:M
Last Name:DEVEREUX
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:FORREST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DRIVE
Mailing Address - Street 2:PHYSICIAN CONTRACTING - SUITE 2300
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-623-7010
Mailing Address - Fax:302-623-0394
Practice Address - Street 1:501 WEST 14TH STREET
Practice Address - Street 2:6TH FLOOR
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801
Practice Address - Country:US
Practice Address - Phone:302-428-6756
Practice Address - Fax:302-428-6750
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005310103G00000X, 103TC0700X
DEB1-0001049103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363236791OtherTAX ID
ILS57751Medicare UPIN
IL363236791OtherTAX ID