Provider Demographics
NPI:1255083390
Name:VAN WAGENEN, ANGELICA (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANGELICA
Middle Name:
Last Name:VAN WAGENEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12922 LYME BAY DR
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2612
Mailing Address - Country:US
Mailing Address - Phone:845-235-0320
Mailing Address - Fax:
Practice Address - Street 1:2000 15TH ST N
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201-2683
Practice Address - Country:US
Practice Address - Phone:845-235-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005915103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical