Provider Demographics
NPI:1689780322
Name:DE VARONA, ANGELA (PHD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:DE VARONA
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 1:1702 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4016
Mailing Address - Country:US
Mailing Address - Phone:336-659-8301
Mailing Address - Fax:336-659-9361
Practice Address - Street 1:1702 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4016
Practice Address - Country:US
Practice Address - Phone:336-659-8301
Practice Address - Fax:336-659-9361
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC045U0OtherBLUECROSSPROVIDER#
NC1897OtherNC PSYCHOLOGY LICENSE#