Provider Demographics
NPI:1831205400
Name:VAN EMBURGH, AMANDA KATHERINE (PSYD)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KATHERINE
Last Name:VAN EMBURGH
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 1:720 OLD GASTON PL
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3878
Mailing Address - Country:US
Mailing Address - Phone:703-864-4444
Mailing Address - Fax:
Practice Address - Street 1:725 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4206
Practice Address - Country:US
Practice Address - Phone:336-607-8523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3620103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical