Provider Demographics
NPI:1598776593
Name:D'ANGELO, GREGG (PHD)
Entity Type:Individual
Prefix:
First Name:GREGG
Middle Name:
Last Name:D'ANGELO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11882 GREENVILLE AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3567
Mailing Address - Country:US
Mailing Address - Phone:972-424-9212
Mailing Address - Fax:972-509-1450
Practice Address - Street 1:11882 GREENVILLE AVE STE 121
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3567
Practice Address - Country:US
Practice Address - Phone:972-424-9212
Practice Address - Fax:972-509-1450
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24947103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX24947OtherTEXAS LICENSE
TX86850AOtherBLUE CROSS ID W/IN GROUP
TX0310641 02Medicaid
TX8B6528Medicare ID - Type UnspecifiedMEDICARE ID W/IN GROUP