Provider Demographics
NPI:1942580857
Name:HAVILAND, ANGELA M
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:HAVILAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2701
Mailing Address - Country:US
Mailing Address - Phone:336-725-8389
Mailing Address - Fax:
Practice Address - Street 1:932 OLD US 70 W
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-2547
Practice Address - Country:US
Practice Address - Phone:828-669-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1399101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)