Provider Demographics
NPI:1639347636
Name:REDWINE, ANGELA M (PHD, LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:REDWINE
Suffix:
Gender:F
Credentials:PHD, LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37111-0640
Mailing Address - Country:US
Mailing Address - Phone:931-507-1212
Mailing Address - Fax:931-507-1217
Practice Address - Street 1:1511 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2343
Practice Address - Country:US
Practice Address - Phone:931-455-6213
Practice Address - Fax:931-455-6225
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0700X
TN2784101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2784OtherLICENSE