Provider Demographics
NPI:1891018628
Name:TATUM FAIRFAX, ANGELA M (LPC, BC-DMT, NCC)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:M
Last Name:TATUM FAIRFAX
Suffix:
Gender:F
Credentials:LPC, BC-DMT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 SILVERSIDE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-5190
Mailing Address - Country:US
Mailing Address - Phone:302-319-3820
Mailing Address - Fax:
Practice Address - Street 1:3618 SILVERSIDE RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-5190
Practice Address - Country:US
Practice Address - Phone:302-319-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEPC-0000438101YP2500X
PAPC005056101YP2500X
MDBC-DMT 1008225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist