Provider Demographics
NPI:1275694614
Name:ANGEL, MYRA HARRILL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:HARRILL
Last Name:ANGEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11828 BLUE SPRUCE RD
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4210
Mailing Address - Country:US
Mailing Address - Phone:703-620-1106
Mailing Address - Fax:703-620-1693
Practice Address - Street 1:380 MAPLE AVE W STE 303
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-5682
Practice Address - Country:US
Practice Address - Phone:703-938-5234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001892103TC0700X
VA0803000078103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool