Provider Demographics
NPI:1679649131
Name:OMAR, TONYA CROCKETT (LPA)
Entity Type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:CROCKETT
Last Name:OMAR
Suffix:
Gender:F
Credentials:LPA
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3500 WESTGATE DR
Mailing Address - Street 2:BLDG. 100 STE. 101
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2567
Mailing Address - Country:US
Mailing Address - Phone:919-423-3431
Mailing Address - Fax:919-403-6106
Practice Address - Street 1:3500 WESTGATE DR
Practice Address - Street 2:BLDG. 100 STE. 101
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2567
Practice Address - Country:US
Practice Address - Phone:919-423-3431
Practice Address - Fax:919-403-6106
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2523103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107031Medicaid